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Cal MediConnect Plan Frequently Asked Questions

What is Santa Clara Family Health Plan Cal MediConnect Plan?

As your local, not-for-profit health plan, Santa Clara Family Health Plan (SCFHP) is here for you. Since 1997, we have worked with our providers and community partners to support the health and wellness of our neighbors. We are excited to offer you the Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect Plan).

The Cal MediConnect Plan is a health plan option for people with Medicare and Medi-Cal. Cal MediConnect plan is part of California’s Coordinated Care Initiative. Cal MediConnect Plan brings your health care and long-term services and supports into one plan so they work together.

Can I join SCFHP Cal MediConnect Plan?

Most people who have both full Medicare and full Medi-Cal can join. For more information on enrolling, go to How to Enroll.

What is Medicare?

Medicare is the federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).

The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services, or CMS.

To contact Medicare:

Call: 1-800-MEDICARE (1-800-633-4227), available 24 hours a day, 7 days a week.

TTY: 1-877-486-2048. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.

Your call is free.

Website: www.medicare.gov

This is the official website for Medicare. It gives you up-to-date information about Medicare.

Does SCFHP Cal MediConnect Plan have a monthly plan premium?

No. There are no premiums for SCFHP Cal MediConnect Plan.

What are the benefits of enrolling in SCFHP Cal MediConnect Plan?

In SCFHP Cal MediConnect Plan, you have one plan, one member ID card, and one phone number to call for help.

As a member of SCFHP Cal MediConnect Plan, you will get:

  • All of your Medicare and Medi-Cal benefits in one health plan, including access to doctors, hospitals, and prescription drugs.
  • One membership card and one phone number to call to get help.
  • Behavioral health care, durable medical equipment, vision care, fitness benefit, and transportation to medical appointments.
  • Long-term services and supports (LTSS), including Community-Based Adult Services (CBAS), and Nursing Facilities (NF).
  • Access to a case manager and care team. Your case manager can answer your questions, help you find community services, assist you in making your medical appointments, and help you talk to your doctors and other providers. A care team may include your doctor, a case manager, or other health professionals that you choose.
  • A personal care plan made just for you and your medical, behavioral health, and LTSS needs.

What does SCFHP Cal MediConnect Plan cover?

SCFHP Cal MediConnect Plan coordinates all of your Medicare and Medi-Cal benefits under one health plan, including:

  • Medical care
  • Prescription medications, including Part D prescription coverage
  • Behavioral health care
  • Long-term services and supports (LTSS)

You can find more information about SCFHP Cal MediConnect Plan’s coverage on our Benefits and Copays page.

What is the service area for SCFHP Cal MediConnect Plan?

You must live in Santa Clara County to enroll in SCFHP Cal MediConnect Plan and to stay a member of the plan.

What are long-term services and supports (LTSS)?

Long-term services and supports (LTSS) are Medi-Cal benefits that help you with ongoing personal care needs. They provide help for people who need help doing everyday tasks like taking a bath, getting dressed, making food, and taking medication. Most of these services are provided at your home or in your community but may be provided in a nursing facility or hospital. LTSS includes:

  • Community-Based Adult Services (CBAS): These are daytime health care services at centers that provide nursing, therapy, activities, and meals for people with certain chronic conditions.
  • Care in a Nursing Facility (NF): A nursing facility provides care for people who cannot safely live at home but who do not need to be in the hospital. SCFHP works with your doctor and your nursing facility to better coordinate your care.

What are in-home support services?

In-Home Supportive Services (IHSS) is a program that allows you to select your provider of in-home care if you need assistance to safely remain in your home. IHSS services may include but not be limited to: Housecleaning, meal preparation, laundry, grocery shopping, personal care, accompaniment to medical appointments and other services. If you need help with your IHSS benefits, contact the County of Santa Clara Social Services Agency:

Call: 1-408-792-1600, Monday through Friday, 8 a.m. to 5 p.m.

Write:

County of Santa Clara Social Services Agency
1888 Senter Rd
San Jose, CA 95112

Website: www.sccgov.org/sites/ssa/other-services/ihss/Pages/ihss.aspx

Can I see my doctors after I enroll in SCFHP Cal MediConnect Plan?

You should check to see if your doctors are in our network. If you are receiving care from a doctor who is not contracted with SCFHP Cal MediConnect Plan, you may be able to continue that care for up to 12 months. For more information, refer to Chapter 1, Section F of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

To find out if your doctor, hospital, or other specialist is in the SCFHP Cal MediConnect Plan network, use our Find a Doctor search tool, check the SCFHP Cal MediConnect Plan Provider and Pharmacy Directory found in Member Materials, or contact SCFHP Cal MediConnect Plan Customer Service:

Call toll free: 1-877-723-4795 (TTY: 711) Monday through Friday, 8 a.m. to 8 p.m.
We have free interpreter services for people who do not speak English.

Write:

Attn: Customer Service Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

What is continuity of care?

When you first join the plan, you can ask to continue to see your current providers. With some exceptions, we are required to approve this request if we can establish that you had an existing relationship with the providers. If we approve your request, you can continue seeing the providers you see now for up to 12 months for services. During that time, your case manager will contact you to help you find providers in our network. After 12 months, we will no longer cover your care if you continue to see providers that are not in our network.

Continuity of care may be provided for services you are currently getting from a doctor. If you get services from an ancillary provider (such as durable medical equipment, medical supplies, or incontinence supplies for either Medicare or Medi-Cal), SCFHP may transition you to an in-network provider.

How do I find out if a prescription drug is covered?

Check the SCFHP Cal MediConnect Plan List of Covered Drugs (Formulary) found in Member Materials. Or you can use the online formulary search tool to find a drug and see what rules apply to it. The online formulary search tool is updated monthly. If you have questions, call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

What is prior authorization?

Prior authorization means that you must get approval from SCFHP before you can get a specific service or drug or see an out-of-network provider. SCFHP Cal MediConnect Plan may not cover the service or drug if you do not get approval.

You do not need SCFHP’s approval if you need urgent or emergency care. Other services requiring prior authorization can be found in Chapter 4, Section D of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

What happens if I receive a bill?

If you get a bill for a covered service, do not pay it. Call SCFHP Cal MediConnect Plan Customer Service right away and make sure to have the bill with you. We will need:

  • The member’s name and address
  • The member identification number on the SCFHP Cal MediConnect Plan 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.

Mail a copy of the itemized bill to:

Attn: Customer Service Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Always carry your SCFHP Cal MediConnect Plan member ID card with you to every doctor’s visit to avoid getting billed by mistake.

If you have questions, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

What should I do if I have a medical emergency?

Call 911 or go to the nearest emergency room. SCFHP Cal MediConnect 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. You do not need SCFHP’s approval if you need urgent or emergency care.

What if I’m not sure how or where to get care?

Call the Nurse Advice Line! Our advice nurse can tell you how or where to get care.

Call: 1-844-803-6962, 24 hours a day, 7 days a week. This call is free.

We have free interpreter services for people who do not speak English.

When should I call the Nurse Advice Line?

  • If you have a health care or behavioral health question.
  • If you are unsure whether to go to the emergency room or urgent care, make a doctor’s appointment, or treat your problem at home.
  • If you or your family member is sick, have a minor injury, or needs medical advice.
  • If you need advice on how and where to get care.

For example, if you are not sure if your condition is an emergency medical condition, the advice nurse can help you decide if you need emergency services or urgent care. The advice nurse can tell you:

  • How and where to get care.
  • What to do if you need care and a health care provider’s office is closed.
  • If you need a referral to a telehealth provider.

In an emergency, you should always call 911 or go to the nearest emergency room.

Our Nurse Advice Line now offers the option of speaking to a doctor via our telehealth service if recommended by the advising nurse to get you the care you need faster without having to leave your house.

I lost my SCFHP member ID card. How do I get a new one?

Log in to mySCFHP or call SCFHP Cal MediConnect Plan Customer Service 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m., to request a new member ID card.

How do I change my Primary Care Provider (PCP)?

Log in to mySCFHP or call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY:711), Monday through Friday, 8 a.m. to 8 p.m. to request changing your PCP.

If your PCP change is approved, the change will usually be effective the first day of the next month. For example, if your PCP change is approved in February, in most cases, you can visit your new PCP on March 1. We will mail you a new SCFHP Cal MediConnect Plan member ID card with the name of your new PCP on it. Once you get your new SCFHP Cal MediConnect Plan ID card, we ask that you destroy your old SCFHP Cal MediConnect Plan ID card(s).

How do I change my phone number or address?

If you have a new phone number or new mailing address, call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m., to update your contact information. You should also tell the Santa Clara County Social Services Agency and Social Security Administration.

To contact Santa Clara County Social Service Agency:

To contact Social Security Administration:

What do I do if I have a problem or complaint?

If you have a problem or complaint, also called a grievance, our Customer Service team will help you. Call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

See Complaints, Grievances & Appeals for more information on what you can do if you have a problem or complaint. You can also refer to the SCFHP Cal MediConnect Plan Member Handbook, Chapter 9. You can view the Member Handbook in Member Materials.

How do I authorize someone to represent me?

If you would like to authorize someone to speak on your behalf as your “representative,” first you must give them legal permission to act for you. To appoint a representative, complete the Appointment of Representative (AOR) form in your language:

Read the instructions on how to complete an AOR form by selecting your language below:

You must give us a copy of the signed form. The form must be renewed each year. SCFHP will also accept an equivalent written notice so long as it includes the following information:

  • Your name, address, and telephone number;
  • The name, address and telephone number of the person you would like to appoint as your representative;
  • Your Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI), or SCFHP Cal MediConnect Plan member ID number;
  • Your appointed representative’s professional status or how you are related to him or her (i.e., friend, family member, lawyer, etc.);
  • What subject(s) you would like the person to know or speak on (i.e., a complaint, any coverage decision, a medical appeal only, etc.);
  • A statement that gives the person permission to act on your behalf and that you allow this person to receive your protected health information (PHI);
  • A statement by the person being appointed that he or she accepts the appointment, and
  • A signature from you and the representative along with the date you both signed the document.

You may send the completed and signed AOR form or equivalent written notice to:

Attn: AOR Review Team
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Or fax it to 1-408-874-1965.

If you have questions, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

What is an advance directive?

You have the right to say what you want to happen if you are unable to make health care decisions for yourself. Before that happens you can:

  • Fill out a written form to give someone the right to make health care decisions for you. This person can be a spouse, family member, friend, or other person you choose. And your rights as a member of SCFHP Cal MediConnect Plan apply to this person.
  • Give your doctors written instructions about how you want them to handle your health care if you become unable to make decisions for yourself.

The legal document you can use to give your direction is called an advance directive. There are different types of advance directives and different names for them. For example, a living will and a power of attorney for health care. You do not have to use an advance directive, but you can if you want to. Find the advance directive form in Member Materials.

At your request, we will send you information about state law regarding advance directives, including any changes to the law, within 90 days after the change is effective.

If you need help or more information, call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

How do I get behavioral health services?

You will have access to medically necessary behavioral health services that are covered by Medicare and Medi-Cal. SCFHP Cal MediConnect Plan provides access to behavioral health services covered by Medicare. Medi-Cal covered behavioral health services are not provided by SCFHP Cal MediConnect Plan, but will be available to eligible SCFHP Cal MediConnect Plan members through the Santa Clara County Behavioral Health Services Department.

Your PCP may provide services to treat mild to moderate mental health conditions such as anxiety or mild to moderate depression. In addition, your PCP may provide screening, brief intervention, and referral to treatment for substance use disorders. For moderate to severe mental health needs, you will be referred to County-contracted services.

Your benefits include the help of a counselor or therapist.

There is no need for prior authorization for these mild to moderate services. The Santa Clara Family Health Plan (SCFHP) Behavioral Health (BH) Services Department will help you find assistance in accessing services. Call SCFHP Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

You can also call Santa Clara County Behavioral Health Services for more help:

  • For the 24/7 Suicide and Crisis Hotline, call 988.
  • For mental health services, 24/7, call 1-800-704-0900.
  • For substance abuse services, call 1-800-488-9919, Monday through Friday, 8 a.m. to 5 p.m.

If you have an urgent mental health need, the County's Mental Health Urgent Care walk-in clinic is located at 871 Enborg Court, Unit 100, San Jose, CA 95128. Hours are 8 a.m. to 10 p.m., seven days a week, including holidays. From 10 p.m. to 8 a.m., use the Mental Health Urgent Care (MHUC) entrance to access emergency psychiatric services. The MHUC phone number is 1-408-885-7855.

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

How to request transportation services

To arrange Non-Emergency Medical Transportation (NEMT) services:

  1. Have your doctor fill out a Physician Certification Statement (PCS) form to request the type of transportation you need.
  2. Tell your doctor to send the completed form to SCFHP by fax to 1-408-874-1957.
  3. Five (5) business days or sooner before your scheduled appointment, log in to mySCFHP. Go to Request Medical Transportation under Quick Links. Complete the form and submit.
  4. We will call you to confirm your transportation request.

To arrange Non-Medical Transportation (NMT) services:

  1. Three (3) business days before your scheduled appointment, log in mySCFHP. Go to Request a Taxi under Quick Links. Complete the form and submit.
  2. We will call you to confirm your transportation request.

Using Non-Medical Transportation

When you use non-medical transportation, you should plan for the following:

  • Be ready for your ride: Your ride is scheduled to arrive up to 60 minutes before your scheduled appointment. For example, if your appointment is at 10 a.m., you should be ready no later than 9 a.m. Your ride may be late because of traffic, scheduling, or other issues. To help your ride get you to your appointment on time make sure you are ready and waiting at the prearranged location at the scheduled time.
  • Group rides: In some instances, this is a ride-sharing transportation service.
  • Curb-to-curb service: In most instances, Non-Medical Transportation is curb-to-curb service not door-to-door.
  • Drivers cannot carry your items.
  • Companion or personal care attendant: If needed, one other person may accompany you. When you call SCFHP Customer Service to schedule transportation, let us know that someone will be accompanying you.

How do I get a Physician Certification Statement (PCS) form?

For more information, refer to the SCFHP Cal MediConnect Plan Member Handbook, Chapter 3, Section G. You can view the Member Handbook in Member Materials.

If you have questions, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

How do you protect my privacy?

This notice describes how your medical information may be used and disclosed. It also describes how you can get access to this information. Please review it carefully.

Notice of Privacy Practices

Aviso de Prácticas de Privacidad

Thông Báo Về Các Biện Pháp Bảo Vệ Quyền Riêng Tư

隐私条例公告

Paunawa ukol sa Mga Gawi sa Pagkapribado

If you have questions, call SCFHP Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

How do I request a copy of member materials?

To request a hard copy of member materials, please call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. You can also use our online form to submit your request.

You can make a standing request to get this document in a language other than English or in an alternate format, such as large print, Braille, or audio. We will keep this information on file for future mailings. You do not need to make a separate request each time. To make or change your request, call SCFHP Cal MediConnect Plan Customer Service, use the online form, or send a request in writing to:

Attn: Customer Service Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Accessibility

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.

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook.

Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect Plan) depends on contract renewal.

Last updated 12/30/2021

H7890_17023W Accepted