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Cal MediConnect Frequently Asked Questions

What is the Santa Clara Family Health Plan Cal MediConnect Plan?

If you have both Medicare and Medi-Cal, you have a health plan option called Cal MediConnect. Cal MediConnect is part of California’s Coordinated Care Initiative. Cal MediConnect brings your health care and long-term services and supports into one plan so your benefits and services work better together.

As your neighbor here in Santa Clara County, Santa Clara Family Health Plan (SCFHP) has been serving our community since 1997. We are excited to offer you the Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan).

Can I join SCFHP Cal MediConnect?

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

Does SCFHP Cal MediConnect have a monthly plan premium?

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

What are the benefits of enrolling in SCFHP Cal MediConnect?

As a member of SCFHP Cal MediConnect, 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, gym membership, and transportation to medical appointments.
  • A 24-hour Nurse Advice Line for help with non-emergency care.
  • Long-term services and supports (LTSS), including Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and Nursing Facilities (NF).
  • Access to a Case Manager and care team. The 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 person that you choose.
  • A personal care plan made just for you and your medical, behavioral health, and LTSS needs.

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

What does Cal MediConnect cover?

With Santa Clara Family Health Plan (SCFHP) Cal MediConnect, your benefits and services work better together–one plan, one card, one phone number to call. You’ll get help from a case manager to coordinate your care, especially during transitions such as leaving the hospital or choosing a new provider. Your case manager can help you:

  • Understand your health plan benefits.
  • Find doctors and specialists within your network.
  • Choose a doctor or change doctors.
  • Make medical appointments.
  • Get authorizations for care, equipment, or supplies.
  • Get long-term services from other community resources.
  • Arrange for transportation.

Read more about case management and care coordination.

What is the service area for the SCFHP Cal MediConnect Plan?

You must live in Santa Clara County to enroll in SCFHP Cal MediConnect 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 medicine. 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.
  • Multipurpose Senior Services Program (MSSP): These are social and health care coordination services for people age 65 and older. In Cal MediConnect, SCFHP will work with your MSSP providers to better coordinate your care.
  • Care in a Nursing Facility: 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.

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

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, you may be able to continue that care for up to 12 months. For more information on continuity of care, see Chapter 1, Section F of the SCFHP Cal MediConnect Member Handbook.

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

Call:

Toll-free: 1-877-723-4795 (TTY: 711)
8 a.m. to 8 p.m., Monday through Friday
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 a Care Team and Care Plan?

Care Team

Do you need help getting the care you need? A care team can help you. A care team will include yourself, your primary and/or specialty doctor, a case manager, and any other health professional that you choose.

A case manager is a person who is trained to help you manage the care you need. You will get a case manager when you enroll in SCFHP Cal MediConnect. This person will help you navigate your health plan benefits and refer you to available county or community resources if SCFHP Cal MediConnect does not provide the services that you need.

You can call us at 1-877-590-8999 (TTY: 711), Monday through Friday, 8:30 a.m. to 5 p.m to ask for a care team.

Care Plan

Your care team will work with you to come up with a care plan. A care plan tells you and your doctors what services you need, and how you will get them. It includes your medical, behavioral health, and long-term services and supports needs. Your care plan will made just for you and your needs.

Your care plan will include:

  • Your health care goals.
  • A timeline for when you should get the services you need.

After your health risk assessment, your care team will call you to talk about your care plan. They will talk to you about services you need. They can also tell you about services you may want to think about getting. Your care plan will be based on your needs. Your care plan is shared with you, your providers, and other care team members to make sure that you get the care and support you need to meet your goals. Your care team will work with you to update your care plan at least every year.

For more information, see Case Management and Care Coordination.

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

Check the SCFHP Cal MediConnect List of Covered Drugs (Formulary) found in Member Materials. If you have questions, call 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 may not cover the service or drug if you don’t get approval.

If you need urgent or emergency care, you don't need to get approval first. See the Cal MediConnect Member Handbook, Chapter 4, to see which services require you to get prior authorization from SCFHP before the service is provided.

What happens if I receive a bill?

If you get a bill for a covered service, do not pay it. Call Customer Service 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 SCFHP member ID card
  • The date and reason for the bill
  • The name of the doctor or hospital
  • The amount of the bill

If you were eligible for the service, we will send the payment to the provider.

If you have already paid the bill for a covered service, send us your bill and proof of any payment you have made. Proof of payment can be a copy of the check you wrote or a receipt from the provider. It is a good idea to make a copy of your bill and receipts for your records. You can call Customer Service to ask for help.

Mail us your request for payment together with any bills or receipts to:

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

You may also call us to request payment. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

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

What should I do if I have a medical 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.

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

Log in to mySCFHP or call Customer Service 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 Customer Service to change your PCP.

If your PCP change is approved, in most cases, the change will 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 member ID card with the name of your new PCP on it.

How do I change my phone number or address?

If you have a new phone number or new mailing address, call SCFHP Cal MediConnect 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, our Customer Service team will help you. Call 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. Or refer to the SCFHP Cal MediConnect Member Handbook, Chapter 9. You can view the Member Handbook in Member Materials.

How do I authorize someone to represent me?

Did you know that when you are talking with SCFHP, you can have a family member, friend, other trusted person, doctor, or other provider discuss your health and benefit information for you? You can name that person as your “representative”. But first you must give them legal permission to act for you.

Your appointed representative can call SCFHP to select your new doctor, help get your prescription filled, or ask a question about benefits. Your appointed representative may act for you in most health care matters with SCFHP, and may use, receive, or disclose your Personal Health Information (PHI) when communicating with SCFHP.

To appoint a representative, call Customer Service and ask for the “Appointment of Representative” form. You can also get the form on the Medicare website at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or in Member Materials. You must give us a copy of the signed form. Please note that an AOR is valid for one year from the date you and the representative sign the form. You may cancel the appointment of your representative at any time.

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 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

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

Your Primary Care Provider (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:

If you have an urgent mental health need, the County's Mental Health Urgent Care walk-in clinic is located at 871 Enborg Court, 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

What transportation services are available to me?

SCFHP provides Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) for members to get medically necessary covered services.

  • NEMT services are for members whose medical or physical condition requires transportation by ambulance, litter van, wheelchair van, or air.
  • NMT services are for members whose medical or physical condition does not require transportation by ambulance, litter van, wheelchair van, or air. Members can use public transportation or private vehicle to get to medically necessary appointments.

How do I request transportation services?

To arrange 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 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.

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

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.

 

 

 

 

 

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. Or 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. 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 Customer Services, 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 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.

Know your rights

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

How can you get an interpreter?

Tell your doctor’s office you’d 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.

Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. This 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 contact the plan 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

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