DualConnect Frequently Asked Questions

Santa Clara Family Health Plan DualConnect (HMO D-SNP) (DualConnect) is a Medicare Medi-Cal Plan for qualifying residents of Santa Clara County. Our mission is to improve the well-being of our members by addressing their health and social needs in a culturally competent manner. We partner with providers and organizations in our shared commitment to the health of our community. Our vision is health for all – a fair and just community where everyone has access to opportunities to be healthy.

SCFHP DualConnect brings your health care and long-term services and supports into one plan so they work together and your health care is made easy.

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

Medicare is the federal health insurance program generally 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.

No. There are no premiums for SCFHP DualConnect.

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

With Santa Clara Family Health Plan (SCFHP) DualConnect, you 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.
• A choice of hundreds of primary care doctors.
• Access to eight hospitals throughout Santa Clara County.
• Access to thousands of specialists.
• 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 care coordinator 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.
• An Individualized Care Plan made just for you and your medical, behavioral health, and LTSS needs.
• $0 copay for prescription drugs.
• Up to $135 for qualified over-the-counter (OTC) items every three months.
• $0 fitness membership at YMCA of Silicon Valley
• Prescriptions available at most national chains and at independent pharmacies in Santa Clara County.
• A 24-hour nurse advice line.
• Resource navigation, health and wellness classes, and in-person support at the SCFHP Blanca Alvarado Community Resource Center in East San Jose.
• Bilingual staff who speak Spanish and Vietnamese plus free interpreter services in any language.

SCFHP DualConnect 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 DualConnect’s coverage on our Benefits and Copays page.

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

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. LTSS includes:

• Community-Based Adult Services (CBAS): These are daytime health care services at centers that provide nursing, physical therapy, social 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.

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: light 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

MSSP (Multipurpose Senior Services Program) is a care management program, designed to work with frail older adults 65 years or older who are at risk of nursing home placement. Their care managers will help to identify problems that could put you at risk for being unable to remain safe in your home. They will assist you in finding viable and acceptable resources so that you have the tools you need to keep your situation stable and for you to remain living independently in your own home for as long as possible. To apply or for more information:

Call: 1-408-350-3200, Monday through Friday, 8 a.m. to 5 p.m.

Website: https://mysourcewise.com/programs-services/care-management/

You should check to see if your doctors are in our network. To find out if your doctor, hospital, or other specialist is in the SCFHP DualConnect network, use our Find a Doctor search tool, check the SCFHP DualConnect Plan Provider and Pharmacy Directory found in Member Materials, or contact SCFHP DualConnect Customer Service:

Call toll free: 1-877-723-4795 (TTY: 711) 7 days a week, 8 a.m. to 8 p.m.
We have free interpreter services for people who do not speak English.

If you are receiving care from a doctor who is not contracted with SCFHP DualConnect, you may be able to continue that care for up to 12 months. For more information, see What is continuity of care? (below) or refer to Chapter 1, of the SCFHP DualConnect Member Handbook in Member Materials.

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, read the instructions and complete the Appointment of Representative (AOR) form in your language:

• English
• Español
• Tiếng Việt
• 中文
• Tagalog

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 Medicare Beneficiary Identifier (MBI), or SCFHP DualConnect 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 DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

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.

Check the SCFHP DualConnect 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 DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

To see if Medi-Cal Rx covers your drugs, check the Medi-Cal Rx List of Covered Drugs at https://medi-calrx.dhcs.ca.gov/home/cdl/

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 DualConnect 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 DualConnect Member Handbook in Member Materials.

If you get a bill for the full cost of health care or drugs, do not pay the bill and send the bill to us. To send us a bill, refer to Chapter 7, Section B of the Member Handbook.

• If we cover the services or drugs, we will pay the provider directly.
• If we cover the services or drugs and you already paid more than your share of the cost; it is your right to be paid back.
• If we do not cover the services or drugs, we will tell you.

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

If you have questions, please call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

Call 911 or go to the nearest emergency room. SCFHP DualConnect 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.

Call your PCP with questions about your health. If they are unavailable after hours, please 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.

Call your PCP with questions about your health. If they are unavailable after hours, please call the Nurse Advice Line.

You can contact the Nurse Advice Call Line with questions about your health or health care. Our licensed healthcare professionals can help you 24 hours a day, 7 days a week. The Nurse Advice Line can help you with:

• Instructions on self-care at home
• What to do if you need care and a healthcare provider’s office is closed
• Advice on whether you should get medical care
• How and where to get care
• Referral to telehealth providers

For example, if you are not sure if your condition is an emergency medical condition, Nurse Advice can help you decide if you need emergency services or urgent care.

In an emergency, you should always call 9-1-1, or go to the nearest hospital.

Log in to mySCFHP or call SCFHP DualConnect Customer Service 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m., to request a new member ID card.

Log in to mySCFHP or call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY:711), 7 days a week, 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 DualConnect member ID card with the name of your new PCP on it. Once you get your new SCFHP DualConnect ID card, we ask that you destroy your old SCFHP DualConnect ID card(s).

If you have a new phone number or new mailing address, call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 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:

• Call 1-877-962-3633 (TTY: 711), 24 hours a day, 7 days a week.
• Visit www.mybenefitscalwin.org to find a local field office or for more information.

To contact Social Security Administration:

• Call 1-800-772-1213, Monday through Friday, 7 a.m. to 7 p.m. (TTY: 1-800-325-0778)
• Visit a local field office: www.ssa.gov/agency/contact
• Visit the website: www.ssa.gov/myaccount

If you have a problem or complaint, also called a grievance, our Customer Service team will help you. Call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 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 DualConnect Member Handbook, Chapter 9. You can view the Member Handbook in Member Materials.

Even if you are not sick now, planning for your future health care is important to ensure you get the care you want. An advance directive allows you to make decisions about your care in situations or when you cannot make decisions for yourself. Let your family, friends, and medical professionals know what you want by:

• Filling 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 DualConnect apply to this person.
• Giving your doctors written instructions about how you want them to handle your health care if you become unable to make decisions for yourself.

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 a California Advance Health Care 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 DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

Behavioral health services are provided for medically necessary mental health and substance use conditions. For behavioral health needs, DualConnect includes: an assessment and linkage to the appropriate treatment. For example, a therapist or psychiatrist.

You can access behavioral health services by contacting:

1. Your PCP to discuss symptoms and treatment options. Your PCP can help treat mild to moderate mental health conditions such as anxiety or depression. In addition, your PCP may provide screening, brief intervention and referral to treatment for substance use disorders.
2. The Santa Clara County Behavioral Health Call Center at 1-800-704-0900. Choose desired language, then option 2 to complete a mental health or substance use screening. If the screening indicates that you have specialty mental health needs, the Call Center will coordinate services for you. If the screening indicates you have mild-to-moderate mental health needs, they may refer you to SCFHP for coordination of those services.
3. SCFHP customer services at 1-877-723-4795.

Your benefits include the help of a counselor or therapist.

A prior authorization is not needed to see an SCFHP in-network provider for mild-to-moderate services, such as:

• Mental health evaluation
• Individual group and family therapy
• Psychological and neurological testing
• Outpatient drug therapy
• Psychiatric consultation
• Outpatient labs

If you have an urgent Behavioral health need, the County's Mental Health Urgent Care (BHUC) 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 BHUC entrance to access emergency psychiatric services. The BHUC phone number is 1-408-885-7855.

If are you are experiencing a suicidal crisis or emotional distress, call the National Suicide Prevention Hotline at 988. You can also text “RENEW” to 741741.

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

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

1. Have your doctor fill out a Transportation 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.

• Download the Transportation Physician Certification Statement (PCS) form
• Call Customer Service to get a form mailed to you
• Fax your request to 1-408-874-1957.

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

If you have questions, please call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

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), 7 days a week, 8 a.m. to 8 p.m.

To request a hard copy of member materials, please call Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 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 DualConnect 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

You can end your membership in DualConnect (HMO D-SNP) during certain times of the year.

Since you have Medi-Cal, you may be able to end your membership with our plan or switch to a different plan one time during each of the following Special Enrollment Periods:

• January to March
• April to June
• July to September

In addition to these three Special Enrollment periods, you may end your membership in our plan during the following periods each year:

• The Annual Enrollment Period, which lasts from October 15 to December 7. If you choose a new plan during this period, your membership in our plan ends on December 31 and your membership in the new plan starts on January 1.
• The Medicare Advantage Open Enrollment Period, which lasts from January 1 to March 31. If you choose a new plan during this period, your membership in the new plan starts the first day of the next month.

There may be other situations when you are eligible to make a change to your enrollment. For example, when:

• You moved out of our service area,
• Your eligibility for Medi-Cal or Extra Help changed, or
• If you recently moved into, currently are getting care in, or just moved out of a nursing home or a long-term care hospital.

Your membership ends on the last day of the month that we get your request to change your plan. For example, if we get your request on January 18, your coverage with our plan ends on January 31. Your new coverage begins the first day of the next month (February 1, in this example).

NOTE: If you're in a drug management program, you may not be able to change plans. Refer to Chapter 5 of the SCFHP DualConnect Member Handbook for more information about drug management programs.

You have the following options if you want to leave our plan:

• Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users (people who have difficulty hearing or speaking) should call 1-877-486-2048. When you call 1-800-MEDICARE, you can also enroll in another Medicare health or drug plan.

Getting medical services and drugs when you are leaving our plan

Until your membership ends in SCFHP DualConnect, you will keep getting your medical services and drugs through our plan. If you leave SCFHP DualConnect, it may take time before your membership ends and your new Medicare and Medi-Cal coverage begins. During this time, you will keep getting your health care and drugs through SCFHP.

• Use our network pharmacies including through our mail-order pharmacy services to get your prescriptions filled.
• If you are hospitalized on the day that your membership in SCFHP DualConnect ends, our plan will cover your hospital stay until you are discharged.

Your membership in SCFHP DualConnect will end in certain situations

These are the cases when SCFHP DualConnect must end your membership in the plan:

• If there is a break in your Medicare Part A and Part B coverage.
• If you no longer qualify for Medi-Cal. Our plan is for people who qualify for both Medicare and Medi-Cal. To be a member of SCFHP DualConnect, you must keep your eligibility with Medi-Cal and Medicare. The State or Medicare may disenroll you if you are determined no longer eligible for Medicare Medi-Cal Plans.
• If you move out of our service area. The SCFHP DualConnect service area is Santa Clara County.
• If you are away from our service area for more than six months.
  • If you move or take a long trip, you need to call SCFHP DualConnect Customer Service to find out if the place you are moving or traveling to is in our plan’s service area.
• If you go to jail or prison for a criminal offense.
• If you lie about or withhold information about other insurance, you have for prescription drugs.
• If you are not a United States citizen or are not lawfully present in the United States.
  • You must be a United States citizen or lawfully present in the United States to be a member of our plan.
  • The Centers for Medicare & Medicaid Services will notify us if you are not eligible to remain a member on this basis.
  • We must disenroll you if you do not meet this requirement.

If you lose your eligibility but can reasonably be expected to regain eligibility within 3 months, then you are still eligible for membership in our plan. If you are within our plan’s 3-month period of deemed continued eligibility, we will continue to provide all Medicare Advantage plan-covered Medicare benefits. However, during this period, we will not continue to cover Medi-Cal benefits that are included under the applicable Medicaid State Plan, nor will we pay the Medicare premiums or cost sharing for which the state would otherwise be liable had you not lost your Medi-Cal eligibility. Medicare cost-sharing amounts for Medicare basic and supplemental benefits do not change during this period.

We can make you leave our plan for the following reasons only if we get permission from Medicare and Medi-Cal first:

• If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
• If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan.
• If you let someone else use your member ID card to get medical care.
  • Medicare may ask the Inspector General to investigate your case if we end your membership for this reason.

We cannot ask you to leave SCFHP DualConnect for any reason related to your health

If you feel that you are being asked to leave our plan for a health-related reason, you should call Medicare at 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.

You should also call the Office of the Ombudsman at 1-888-452-8609 (TTY: 711), Monday through Friday from 8 a.m. to 5 p.m. See Chapter 2, Section I of the SCFHP DualConnect Member Handbook for more information on the Office of the Ombudsman. Find a copy of the SCFHP DualConnect Member Handbook in Member Materials.

You have the right to make a complaint if we end your membership in our plan

If we end your membership SCFHP DualConnect, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint, or grievance, about our decision to end your membership. For more information on how to make a complaint, see the Complaints, Grievances & Appeals section of our website or refer to Chapter 9 of the SCFHP DualConnect Member Handbook. Find a copy of the SCFHP DualConnect Member Handbook in Member Materials.

If you have questions or would like more information on when we can end your membership, you can:

• Call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
• Call Heath Care Options at 1-844-580-7272, Monday through Friday from 8 a.m. to 6 p.m. TTY users should call 1-800-430-7077.
• Call the California Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222, Monday through Friday, 8 a.m. to 5 p.m. For more information or to find a local HICAP office in your area, please visit https://mysourcewise.com/programs-services/medicare-options/.
• Call the Office of the Ombudsman at 1-855-501-3077, Monday through Friday from 9 a.m. to 5 p.m. TTY users should call 1-855-847-7914.
• Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
• See Chapter 10 of the Member Handbook for more information on ending your membership in SCFHP DualConnect.

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

If you are more comfortable speaking a language other than English, SCFHP 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 DualConnect materials written in other languages.

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.