Call Member Services right away to request a new one.
Call Member Services to update your contact information. You should also call the Santa Clara County Social Services Agency at 1-877-962-3633.
After you have selected a PCP in our network, call Member Services to make the change. If we can make the change you want, in most cases the change to your new PCP will be effective the first day of the next month. For example, if you ask to change health care providers in February, in most cases, you will be able to visit your new PCP on March 1. We will mail you a new ID card.
- Have continuity of care medical needs, or
- Have been a Kaiser member within the last six months, or
- Received care from a PAMF PCP within the last 24 months, or
- Have an immediate family member living in the same household who is receiving care from Kaiser or PAMF.
You must get covered dental services through Denti-Cal. Contact Denti-Cal for more information about covered dental services and providers in Santa Clara County:
- Toll Free 1-800-322-6384
SCFHP may also pay for dental care in certain circumstances. Services may include topical fluoride varnish for members younger than 6 years of age through the PCP, drugs prescribed by a dentist based upon medical need, dental services for radiation treatment, and dental anesthesia. Please note that authorization from SCFHP may be required.
The Medi-Cal FFS dental program is known as Denti-Cal. In Denti-Cal, you can go to any dentist who accepts Denti-Cal. You may choose a dentist who accepts Denti-Cal for each service he/she provides. Find out more information about Denti-Cal.
30-45 days are allowed to process a Medi-Cal application not involving a disability. If you are applying for Medi-Cal based on a disability, your application process may take up to 90 days depending on how quickly you complete the disability information and when your doctors and hospitals submit your medical records. If you have an immediate medical or dental need, such as pregnancy or a severe illness, indicate this need on your application and your application may be processed more quickly.
No, you must be a resident of California to get Medi-Cal. A California resident is someone who lives in California and plans to stay, or someone who is looking for work in California.
You can have both. You must declare your other insurance coverage when you apply for Medi-Cal.
Yes, you can apply as soon as you know you are pregnant.
The level of benefits you will receive may be different depending on whether you are a citizen or national, legal permanent resident, other satisfactory immigration status, or undocumented.
Some services, which are not provided through a Medi-Cal managed health or dental plan, are contracted directly with health care providers to deliver covered Medi-Cal services. In these cases, you may choose a doctor, dentist, or other provider, who accepts Medi-Cal payments for each service he/she provides at the Medi-Cal payment rate. The provider bills Medi-Cal for services through an entity known as the fiscal intermediary, which is under contract with the California Department of Health Care Services (DHCS) to process Medi-Cal claims and issue reimbursement.
Medi-Cal managed care health plans are like HMO health plans. They help manage your care or your child's care. This may include helping you to find doctors and specialists, having a 24-hour nurse advice phone line, having member services to assist you, helping with transportation to medical visits, and more. The health plan will also help you get services that you or your child need that are not covered by the plan. If you or your child:
- Receives In-Home Support Services (IHSS), contact your social worker to find out if you can get more IHSS hours.
- Is a client of a Regional Center, contact your caseworker for assistance.
If you or your child are enrolled in a Medi-Cal managed care plan and want to choose another Medi-Cal managed care plan for any reason, you may do so at any time. Call Health Care Options (HCO) toll free at 1-800-430-4263, 8:00 a.m. to 5:00 p.m., Monday-Friday and HCO can enroll you in the new plan. You may also complete an Enrollment Choice Form and mail it to HCO:
Department of Health Care Services
Health Care Options
P.O. Box 989009
West Sacramento, CA 95798-9850
Health Care Options will send you a letter within 15 to 45 days telling you that the health plan change has taken place. You must see your present doctor until you get the letter from Health Care Options.
If your Medi-Cal benefits are on hold, you should contact Social Services to talk to your eligibility worker. The eligibility worker will inform you if your benefits can be reinstated. If you do not know how to reach your eligibility worker, you can call the Social Services office in your area at the following numbers:
- Assistance Application Center: 1-408-758-3800, 1-877-962-3633
- North County Office: 1-650-988-6200
- South County Office: 1-408-758-3300
- General Assistance Services 1-408-793-8900
- Children’s Health Initiative: 1-888-244-5222
An HMO is a Health Maintenance Organization, which is a network of health care providers including doctors, hospitals, pharmacies, and other medical facilities and professionals. The network works together to manage the quality and cost of each member's health care.
Each HMO member selects a Primary Care Provider (PCP) from a directory of participating physicians in the areas of general practice, family practice, internal medicine or pediatrics. The PCP coordinates all of the member's health care needs. If the PCP can effectively provide care, the PCP will. If the PCP determines a specialist is needed, the PCP will refer the member to a Participating Specialist in the HMO network.
HMOs are designed to manage the costs of medical care, which means members enjoy lower out-of-pocket expenses compared to traditional medical insurance. Visits to the doctor's office, hospital charges and many other medical care expenses are covered at 100% after a small co-payment such as $5 or $10 per visit.
Generally, prescription drugs, routine physicals, lab tests, vision exams, well-baby care, and maternity visits are covered. HMO plans do not require you to pay an annual deductible before services are covered. HMO providers conveniently take care of most paperwork, so members do not have to complete claim forms.
Some people who are accustomed to selecting their own health care providers and facilities find working with a Primary Care Physician system to be inconvenient or restrictive at first. However, HMO members who recognize the cost-savings, quality care and conveniences they enjoy with managed care are generally satisfied with the trade-off. No benefits are paid if a member decides to go to a health care provider that is not in the network.
The first thing you should do if you need to see a specialist is talk with your Primary Care Provider (PCP). Your PCP will be able to decide whether you need a referral to an SCFHP specialist or an authorization for other specialists outside of the SCFHP network. For non-urgent specialist referrals, please make it a point to talk to your doctor before the matter becomes urgent.
If you have Santa Clara Family Health Plan, vision benefits are provided through the vision plan, VSP. Contact VSP online or call 1-800-877-7195 for help finding a vision provider. Be sure to let your selected vision provider know that you are a member through the Santa Clara Family Health Plan.
- Mental Health Services: 1-800-704-0900
- Suicide and Crisis Hotline: 1-855-278-4204
- Substance Use Services: 1-800-488-9919
In case of emergency, call 911 or go to the nearest emergency room. SCFHP Cal MediConnect covers emergency services in the United States and its territories. Show your SCFHP member ID card to the hospital so they know who to bill.
If you believe that you have been billed by mistake for a covered service, notify us as soon as possible. Send us all of the information listed below:
- A copy of the bill;
- Proof of payment, if you paid the bill;
- The member’s name and address;
- The member identification number on the member ID card;
- The name and address of each provider paid;
- The date and reason for the bill; and
- A letter asking SCFHP to refund the money you paid or asking us to tell the provider to stop billing you.
Send all of the above information to:
Customer Service Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
You need to send this information within 180 calendar days of the date of service. If you have paid the bill, the proof of payment must be acceptable to SCFHP.
If you are not able to send your request within 180 calendar days of the date of service, then when you send your written request for refund, include an explanation and/or other proof that you tried, in good faith, to send us the request within the 180 calendar days. SCFHP will take your request and additional information into consideration.
Note: If you receive bills for the services below, please do not send them to SCFHP. These services are covered through other programs. You can contact the numbers listed below for payment information:
- AFP (Alpha Fetal Protein) screenings: Contact the Extended AFP Program at 1-866-718-7915
- Mental Health services: Contact Access mental health at 1-800-491-9099