Benefits & Copays

• Acupuncture
• Behavioral health services (mental health and substance abuse treatment)
• Chiropractic services
• Dental care (You must get covered dental services through Medi-Cal Dental. These services are a limited benefit. Contact Medi-Cal Dental toll free at 1-800-322-6384 (TTY: 1-800-735-2922) for more information about covered dental care or go to www.denti-cal.ca.gov.)
• Diabetes Prevention Program
• Doctor visits
• Durable medical equipment
• Emergency services, including ambulance
• Fitness benefit. See the Fitness Benefit page for more information.
• Hearing services, including hearing aids, up to $1,510 maximum allowance per member for both ears combined per fiscal year (July 1 – June 30)
• Hospital stay
• Lab tests, X-rays, or other medical tests
• Long-term services and supports (LTSS), including Community-Based Adult Services (CBAS), and Nursing Facilities (NF). LTSS is not a benefit for SCFHP Cal MediConnect Plan members outside of Santa Clara County service area.
• Occupational, physical, or speech therapy
• Prescription and over-the-counter drugs
• Skilled nursing care
• Transportation services: non-emergency medical transportation and non-medical transportation
• Urgent care
• Vision care: one routine exam every year (a referral may be required) and up to $200 for eyeglasses (frames and lenses) or up to $200 for contact lenses every two years. Benefits are provided through Vision Service Plan (VSP).

• Tier 1 drugs are generic drugs. The copay is $0.
• Tier 2 drugs are brand name drugs. The copay is from $0 to $9.85, depending on your income of low-income subsidy (highest cost-sharing tier).
• Tier 3 drugs are non-Medicare prescription drugs that are covered by Medi-Cal. The copay is $0.
• Tier 4 drugs are non-Medicare over-the-counter (OTC) drugs that are covered by Medi-Cal. The copay is $0.

Ask us to make a coverage decision. A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

Go to Coverage Decisions & Exceptions to learn how to ask for a coverage decision about a drug.

To ask for a coverage decision, contact us, or ask your representative or doctor to ask us for a decision.

Call us toll free at: 1-877-723-4795 (TTY: 711), Monday through Friday 8 a.m. to 8 p.m.

Fax: 1-408-874-1957

Write:

Attn: Utilization Management
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

After you ask and we get all of the information we need, it usually takes 5 business days for us to make a decision unless your request is for a Medicare Part B prescription drug. If your request is for a Medicare Part B prescription drug, we will give you a decision no more than 72 hours after we receive your request. If we do not give you our decision within 14 calendar days (or 72 hours for a Medicare Part B prescription drug), you can appeal. An appeal is a way for you to challenge our action if you think we made a mistake.

Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. The letter will explain why more time is needed. We cannot take extra time to give you a decision if your request is for a Medicare Part B prescription drug.

Yes. If you need a response faster because of your health, ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours (or within 24 hours for a Medicare Part B prescription drug).

However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. The letter will explain why more time is needed. We cannot take extra time to give you a decision if your request is for a Medicare Part B prescription drug.

Start by contacting SCFHP Cal MediConnect Plan to ask us to cover the health services you need. You can also have your doctor or your authorized representative contact us.

• Call us toll free at 1-877-723-4795 (TTY: 711), Monday through Friday 8 a.m. to 8 p.m.
• Or fax us at 1-408-874-1957.

You must meet the following two requirements to get a fast coverage decision:

1. You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for care or an item you already got.)
2. You can get a fast coverage decision only if the standard 14 calendar day deadline (or the 72 hour deadline for Medicare Part B prescription drugs) could cause serious harm to your health or hurt your ability to function.
   • If your doctor says that you need a fast coverage decision, we will automatically give you one.
   • If you ask for a fast coverage decision without your doctor’s support, we will decide if you get a fast coverage decision.
     • If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead.
     • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
     • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of a fast coverage decision. For more information about the process for making complaints, including fast complaints, refer to Section 10 of your Member Handbook.

After the coverage decision is approved, you will get the service or item within:

• 14 calendar days for standard coverage decisions
• 72 hours of when you asked for a fast coverage decision

For Medicare Part B prescriptions drugs, you will be approved within:

• 72 hours for a standard coverage decision
• 24 hours for a fast coverage decision.

If the answer is No, we will send you a letter telling you our reasons for saying No.

If we say No, you have the right to ask us to change this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Refer to the section of our website about the appeals process for more information.

You can call us toll free at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

SCFHP Cal MediConnect Plan will generally pay for the health care services, behavioral health services, and long-term services and supports you get as long as you are eligible and the criteria below are met. To be covered:

• The care you get must be a plan benefit.
• The care must be determined medically necessary by meeting a set of medical criteria that is used nationally and by SCFHP Cal MediConnect Plan.
• For medical services, you must have a network primary care provider (PCP) who has ordered the care. As a plan member, you must choose a network provider to be your PCP.
  • In some cases, your PCP must direct you to other network providers before you can see those other network providers. This is called a referral.
  • You do not need a referral from your PCP for emergency care, urgent care, or to see a woman’s health provider. You can get other kinds of care without having a referral from your PCP. To learn more about this, see the SCFHP Cal MediConnect Plan Member Handbook found in Member Materials.
• You must get your care from network providers, except for limited exceptions.

For detailed information on limitations and restrictions, see SCFHP Cal MediConnect Plan Member Handbook found in Member Materials.

Each year, SCFHP Cal MediConnect Plan looks for changes and advances in health care that may improve your care. We study new treatments, medicines, procedures, and devices. We refer to this as “new technology.”

To consider the use of any new technology, we look at related scientific reports and other information from the government and medical specialists. We also consider value, how well it works, and safety standards. After careful review, we then decide if the new technology should be covered as a health benefit. Members and providers may submit requests directly to SCFHP to review new technology. You can call us toll free at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m., or fax us at 1-408-874-1957.

You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP Cal MediConnect Plan Customer Service for help.

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. Tell your doctor you would like an interpreter for your visit.

Know your rights

• You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
• When you go to the doctor, interpreters are available 24-hours a day.
• You can ask for SCFHP Cal MediConnect Plan materials in English, Spanish, Simplified Chinese, Tagalog, and Vietnamese.

How can you get an interpreter?

Tell your doctor’s office you would 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.