Benefits & services
This page explains your covered services as a member of Santa Clara Family Health Plan (SCFHP) Medi-Cal. Your covered services are free as long as they are medically necessary and provided by an in network provider. You must ask us for pre-approval (prior authorization) if the care is out-of-network except for sensitive services, emergencies and some urgent care services. With SCFHP's Medi-Cal Plan, your covered benefits and services include*:
- Chiropractic services
- Dental services provided by Medi-Cal Dental; call Medi-Cal Dental at 1-800-322-6384 (TTY: 1-800-735-2922) or visit their website at www.smilecalifornia.org
- Durable medical equipment (DME)
- Early and periodic screening, diagnosis, and treatment (EPSDT) services for infants, children, and youth under the age of 21
- Emergency services, including ambulance
- Hearing services
- Hospice and palliative care
- Hospital stay
- Incontinence creams and washes
- Laboratory and radiology services, such as x-rays
- Long-term services and supports (LTSS): long-term care, Community-Based Adult Services (CBAS)
- Maternity and newborn care
- Mental health services
- Outpatient (ambulatory) services
- Pediatric services
- Podiatry services
- Prescription drugs are covered through Medi-Cal RX; call Medi-Cal RX at 1-800-977-2273 (TTY: 711) or visit their website at www.Medi-CalRx.dhcs.ca.gov
- Preventive and wellness services, including chronic disease management
- Speech therapy
- Substance use disorder treatment services
- Transportation to medical appointments
- Non-emergency medical transportation (NEMT)
- Non-medical transportation (NMT)
- Vision services: routine eye exam and eyeglasses once every 24 months
*Restrictions and limitations may apply.
Effective January 1, 2022
- The Health Homes Program has been replaced by Enhanced Care Management (ECM). ECM is a benefit that provides extra care coordination services to members with highly complex needs. This new benefit can help you get the care you need to stay healthy and coordinate the care you get from different doctors and others involved in your care. Ask your doctor if you are eligible for ECM.
- SCFHP is now offering Community Supports. Community Supports are medically-necessary services that helps members stay out of the hospital and nursing facilities and live more independently. SCFHP Community Supports include resources for housing navigation, help with rental deposits, help with transitioning from nursing facility back to the home, community, or assisted living, and connection to medically tailored meals or medically-supportive foods.
- Multipurpose Senior Services Program is now covered by a waiver program, and is no longer covered by SCFHP.
- Your pharmacy benefit is now managed by Medi-Cal Rx.
- Major organ transplants are covered by SCFHP.
Effective April 1, 2022
- The Provisional Postpartum Care Extension Program has been replaced with the new Postpartum Care Extension Program. The Postpartum Care Extension Program provides extended coverage for Medi-Cal members during both the pregnancy and after pregnancy. It extends coverage by SCFHP for up to 12 months after the end of the pregnancy regardless of income, citizenship, or immigration status and no additional action is needed.
- SCFHP is now offering Rapid Whole Genome Sequencing (rWGS), including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing to Medi-Cal members who are one year of age or younger and receiving inpatient hospital services in an intensive care unit. rWGS is an emerging method of diagnosing conditions in time to affect ICU care of children one year of age or younger.
Effective July 1, 2022
- Minors may only get the following services without their parent or guardian’s permission if they are 12 years old or older:
- Outpatient mental health care for (minors age 12 or older):
- Sexual assault (no lower age limit)
- Physical assault
- Child abuse
- When you have thoughts of hurting yourself or others (minors age 12 or older)
- HIV/AIDS prevention/testing/treatment
- Sexually transmitted infections prevention/testing/treatment
- Substance use disorder treatment services (minors age 12 or older). For more information see “Substance use disorder treatment services” in this handbook.
- Outpatient mental health care for (minors age 12 or older):
If a member is under 18 years old, they can go to a doctor without permission from their parents or guardian for these types of care:
- Family planning/birth control
- Abortion services
For pregnancy testing, family planning services, birth control, or sexually transmitted infection services, the doctor or clinic does not have to be part of the SCFHP network. Members can choose any Medi-Cal provider and go to them for these services without a referral or pre-approval (prior authorization). Services from an out-of-network provider not related to sensitive care may not be covered. For help finding a doctor or clinic giving these services, or for help getting to these services (including transportation), you can call Customer Service at 1-800-260-2055 (TTY: 711).
Minors can talk to a representative in private about their health concerns by calling the 24/7 SCFHP Nurse Advice Line at 1-877-509-0294.
- New Benefits and Services:
- Asthma prevention
- Chemotherapy & Radiation therapy
- Cognitive health assessment
- Community health worker services
- Rapid Whole Genome Sequencing
- Benefits and Services removed:
- Dental services - limited (performed by medical professional/PCP in a medical office)
- SCFHP covers an annual brief cognitive health assessment for members who are 65 years of age or older, and are otherwise not eligible for a similar assessment as part of an annual wellness visit under the Medicare Program. A cognitive health assessment looks for signs of Alzheimer’s disease or dementia.
See the Member Handbook in Forms & Documents for a complete list of covered services.
Unsure about what is covered? Call Customer Service at 1-800-260-2055 (TTY: 711).
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 Customer Service at 1-800-260-2055 (TTY: 711), Monday through Friday, 8:30 a.m. to 5 p.m.