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Benefits & Copays

Santa Clara Family Health Plan (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), which consists of Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and Nursing Facilities (NF)

You can find a description of the 2020 benefits and copays in the sections below.

For more information, call SCFHP Cal MediConnect Customer Service or read the SCFHP Cal MediConnect Member Handbook and Summary of Benefits.

Annual Notice of Changes (ANOC)

Member Handbook

Summary of Benefits

Provider and Pharmacy Directory

List of Covered Drugs (Formulary)

List of Durable Medical Equipment (DME)

Prior Authorization Requirements
Step Therapy Requirements
Language Assistance Services
Nondiscrimination Notice

Frequently asked questions

Benefits

SCFHP Cal MediConnect covers all services covered by Medicare and Medi-Cal. Benefits include:
  • 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. A fitness center membership to a Silver&Fit® fitness club or exercise center near you that takes part in the program. Or a home fitness program with a choice of up to two (2) home fitness kits each benefit year. For more information, go to www.silverandfit.com.
  • 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), Multipurpose Senior Services Program (MSSP), and Nursing Facilities (NF). LTSS is not a benefit for SCFHP Cal MediConnect 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 VSP.
Prior authorization may be required. Some services are covered only if your doctor or other network provider gets approval from us first. This is called prior authorization. For more information on which services require prior authorization, refer to the SCFHP Cal MediConnect Member Handbook.

Cost-sharing - premiums and copays

You do not pay a monthly premium for your SCFHP Cal MediConnect benefits.
 
For some drugs, you may be charged an out-of-pocket cost called a copay. This is a fixed amount (for example, $3.60) you pay each time you get that drug. You pay the copay at the time you get the drug.
 
Every drug on our SCFHP Cal MediConnect Drug List is in one of 4 cost-sharing tiers. Copays are listed by tiers. Tiers are the groups of drugs in the SCFHP Cal MediConnect formulary.
  • Tier 1 drugs are generic drugs. The copay is $0.
  • Tier 2 drugs are brand name drugs. The copay is from $0 to $8.95, depending on your income (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.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to your SCFHP Cal MediConnect Member Handbook.
To learn more about how we must obtain information and update our systems to have the correct cost-sharing for low-income subsidy beneficiaries, see the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence policy.

Not sure if it's covered?

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.

How to ask for a coverage decision for drugs (including exceptions)

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

How to ask for a coverage decision to get medical care, behavioral health care, or certain long-term services and supports (MSSP, CBAS, or NF services)

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

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

You can fax us at: 1-408-874-1957

You can write to us at:

Attn: Utilization Management
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA  95158
 
How long does it take to get a coverage decision?
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.
 
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 can’t take extra time to give you a decision if your request is for a Medicare Part B prescription drug
 
Can I get a coverage decision faster?
Yes. If you need a response faster because of risk to 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 can’t take extra time to give you a decision if your request is for a Medicare Part B prescription drug.
 
Asking for a fast coverage decision:
  • Start by calling or faxing our plan to ask us to cover the health services you need.
  • Call us 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 also have your provider or your authorized representative call or fax us.
You must meet the following two requirements to get a fast coverage decision:
  • 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.)
  • 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, see Section 10 of your Member Handbook.)
If the coverage decision is Yes, when will I get the service or item?
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 coverage decision is No, how will I find out?
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. See the section of our website about the appeals process for more information.

How can I find out the status of my coverage decision?

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

Limitations and restrictions

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. For detailed information on limitations and restrictions, see the SCFHP Cal MediConnect Member Handbook found in Member Materials. To be covered:
  • The care you get must be a plan benefit.
  • The care must be determined necessary by meeting a set of medical criteria that is used nationally and by SCFHP.
  • 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 providers in the plan’s network before you can see those other providers. This is called a referral. You do not need a referral from your PCP for emergency care or urgently needed 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 Member Handbook found in Member Materials.
  • You must get your care from network providers, except for limited exceptions.

Evaluation of New Technology

Each year, SCFHP 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 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.

How to get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect

You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect by contacting the SCFHP Grievance and Appeals Department:

Call:
Toll Free: 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Fax: 1-408-874-1970

Write:
Attn: Grievance and Appeals 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 Customer Service for help.

If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.

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 call 1-877-723-4795 (TTY: 711) or read the Member Handbook.

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

Last updated 01/08/2020

H7890_15083W Accepted