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Member FAQ

General frequently asked questions

Cal MediConnect members, please see Cal MediConnect FAQs

If you have questions about Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan), please visit the Cal MediConnect FAQ page.

Medi-Cal members can also see the Medi-Cal FAQs

If you have questions about Santa Clara Family Health Plan Medi-Cal Plan, please visit the Medi-Cal FAQ page.

I lost my Member ID Card. How do I get a new one?

There are two ways to get a new SCFHP ID card:

How do I change my address?

Call Customer Service to update your contact information.

You also need to call the Santa Clara County Social Services Agency and Social Security Administration to change your address.

Santa Clara County Social Service Agency

Social Security Administration

How do I change my primary care provider (PCP)?

There are several ways to change your PCP:

  • Login to the mySCFHP member portal to request the change.
  • Call Customer Service at 1-800-260-2055 to change your PCP.

If we can make the change you want, then 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 your PCP in February, in most cases, you will be able to visit your new PCP on March 1.

Each time you change your PCP, we will mail you a new SCFHP member ID card within two weeks. The new ID card will have your new PCP printed on it.

I am a Santa Clara Family Health Plan Medi-Cal member, and I would like to go to Kaiser or Palo Alto Medical Foundation. How does this process work?

Providers in SCFHP's Kaiser network and Palo Alto Medical Foundation (PAMF) network are not accepting new Medi-Cal patients. You may be able to select a primary care provider (PCP) in these networks if you meet certain requirements:

  • 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.

How to Choose Kaiser:

Call SCFHP Customer Service at 1-800-260-2055 (TTY: 711). Even if you selected Kaiser when you enrolled in Medi-Cal and completed your choice packet, you will need to call SCFHP Customer Service. Please note that if your selection of Kaiser is approved, the change is effective on the first day of the following month. If your choice of Kaiser is not approved, we cannot guarantee that services provided by Kaiser will be covered, even if Kaiser agrees to see you for an appointment.

How to Choose a Palo Alto Medical Foundation (PAMF) PCP:

If you selected a Palo Alto Medical Foundation PCP when you enrolled in Medi-Cal and completed your choice packet, we will check to see if you meet the criteria. If you do, your Palo Alto Medical Foundation coverage will start the first day of the following month. You will get an SCFHP ID card in the mail with your PCP’s information on it. You can also call SCFHP Customer Service at 1-800-260-2055 (TTY: 711) to request a Palo Alto Medical Foundation PCP. Please note that if your selection is approved by Palo Alto Medical Foundation, the change is effective on the first day of the following month. If your choice of Palo Alto Medical Foundation is not approved, we cannot guarantee that services provided by Palo Alto Medical Foundation will be covered, even if Palo Alto Medical Foundation agrees to see you for an appointment.

How do I apply for Medi-Cal?

There are several ways to apply for Medi-Cal:

How soon can I get Medi-Cal?

30-45 days are allowed to process a Medi-Cal application that does not involve a disability. If you are applying for Medi-Cal based on a disability, your application process may take up to 90 days. It depends on how quickly you complete all the 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, be sure to include it on your application. This way, your application may be processed faster.

How do I pay my monthly premiums for Medi-Cal?

If you qualify for no-cost Medi-Cal, you will receive Medi-Cal services at no cost to you. If you qualify for share of cost (SOC) Medi-Cal, you will pay a certain amount only in the month you have medical expenses. Once you pay your SOC, Medi-Cal will pay the rest of your covered medical bills for that month.

Can I enroll in Medi-Cal even if I don't live in California?

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.

What if I currently have insurance, but would like to switch to Medi-Cal?

You can have both. You must declare your other insurance coverage when you apply for Medi-Cal.

If I am pregnant, can I apply for my child before he/she is born?

Yes, you can apply as soon as you know you are pregnant.

What are the citizenship and immigration requirements for Medi-Cal?

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.

What is Medi-Cal Fee-For-Service (FFS)?

Some services, which are not provided through a Medi-Cal managed health or dental plan, are contracted directly with healthcare 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.

What is a Medi-Cal managed care health plan?

Medi-Cal managed care health plans are like HMO health plans. They help manage your care or your child's care. This may include the following:

  • Helping you to find doctors and specialists,
  • A toll-free 24/7 Nurse Advice Line,
  • Customer Service Representatives available to help you,
  • Arrange transportation to medical appointments, 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.

How can I change to a different Medi-Cal managed care health plan for myself or my child?

If you or your child are enrolled in a Medi-Cal managed care plan and want to choose another Medi-Cal managed care plan, you can at any time. Call Health Care Options (HCO) toll-free at 1-800-430-4263, 8 a.m. to 5 p.m., Monday through Friday. HCO can help you enroll in a new plan.

You can also complete an Enrollment Choice Form and mail it to HCO’s mailing address:

Department of Health Care Services
Health Care Options
P.O. Box 989009
West Sacramento, CA 95798-9850

When HCO receives your call or form, HCO 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 HCO.

I have been informed that my Medi-Cal benefits are on hold. What should I do?

If your Medi-Cal benefits are on hold, you should contact the Santa Clara County Social Services Agency (SSA) 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 or visit the SSA office in your area:

Assistance Application Center
Phone: 1-408-758-3800 or 1-877-962-3633
Address: 1867 Senter Road, San Jose, CA 95112

North County Office
Phone: 1-650-988-6200
Address: 1330 W Middlefield Road, Mountain View, CA 94043

South County Office
Phone: 1-408-758-3300
Address: 379 Tomkins Court, Gilroy, CA 95020

General Assistance Services
Phone: 1-408-793-8900
Address: 1919 Senter Road, San Jose, CA 95112

Children's Health Initiative
Phone: 1-888-244-5222

Source: www.sccgov.org

What do I need to do in order to see a specialist?

The first thing you should do if you need to see a specialist is talk with your primary care provider (PCP). Your PCP will decide whether you need a referral to an SCFHP specialist or an authorization for  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.

How do I get behavioral health services?

Behavioral health services covered by Medi-Cal are provided through SCFHP plan providers and the County of Santa Clara. Your primary care provider (PCP) may provide services to treat mild to moderate mental health conditions. You can get specialty mental health services from Santa Clara County Behavioral Health Services.

To get services, contact your PCP or call the Santa Clara County Behavioral Health Call Center at the following numbers:

If you have questions, please call SCFHP Customer Service at 1-800-260-2055 (TTY: 711).

If you think you are having a medical or psychiatric emergency, call 911 or go to the nearest emergency room.

What should I do if I have a medical emergency?

In case of emergency, call 911 or go to the nearest emergency room.

Santa Clara Family Health Plan Medi-Cal plan 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.

What happens if I receive a bill?

If you get a bill for a covered service, do not pay it. Call us right away. Make sure to have the bill with you. We will need:

  • The member's name and address
  • The member identification number on the member ID card
  • The date and reason for the bill
  • The name of the doctor or hospital
  • The amount of the bill

Please send us a copy of the itemized bill to review. If you were eligible for the service, we will send the payment to the provider. If you have paid the bill, send us the proof of payment.

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 90 calendar days of the date of service. If you have paid the bill, the proof of payment must be acceptable to SCFHP.

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:

  • For AFP (Alpha Fetal Protein) screenings, call the Extended AFP Program at 1-866-718-7915.
  • For mental health services, call ACCESS at 1-800-491-9099.