Medi-Cal Frequently Asked Questions

People in many different situations qualify for Medi-Cal. Medi-Cal covers qualifying low-income individuals, families, seniors (ages 65 and older), and people with disabilities.

To be eligible for Medi-Cal, you must be:

• A California resident. A California resident is someone who lives in California and plans to stay, or someone who is looking for work in California.
• A member of a family whose income falls within the Medi-Cal eligibility guidelines.
• If you are 27-49 years old, you must be a U.S. citizen or legal permanent resident.

Children, young adults, and older adults are eligible, regardless of immigration status, if they:

• Live in California
• Are younger than 26 years old or older than 50

You may automatically be eligible for Medi-Cal if you receive cash assistance under one of the following programs:

• SSI/SSP (Supplemental Security Income/State Supplemental Program)
• CalWORKs (California Work Opportunity and Responsibility to Kids), previously called Aid to Families with Dependent Children (AFDC)
• CalFresh
• Refugee Assistance
• Foster Care or Adoption Assistance Program

To see if you qualify, go to the MyBenefits CalWIN website.

You can have both. You must declare your other insurance coverage when you apply for Medi-Cal.

Yes, you can apply as soon as you know you are pregnant.

For eligible adults, there is no premium, no co-payment, and no out-of-pocket costs. Children have a monthly premium of $0 to $13 per child, up to a family maximum of $39 per month.

The Medi-Cal program offers many covered benefits to members. Review SCFHP Medi-Cal Member Handbook for detailed information about SCFHP's Medi-Cal Managed Care plan. The Member Handbook has information on benefits and services, exclusions, limitations, and how to receive benefits and services. Benefits include:

• Most doctor visits with contracted providers for covered benefit services
• Preventive care and immunizations
• Prescriptions (available through Medi-Cal Rx)
• Hospital stays
• Emergency services, including ambulance
• Family planning
• OB-GYN services and pregnancy care
• Lab and x-ray services
• Health education
• Vision care (some restrictions apply, available through VSP)
• Dental care (available through Smile California)
• Behavioral health (mental health and substance abuse) services
• Transportation to medical appointments
• Long-term services and supports (LTSS), including long-term care in a nursing facility, Community-Based Adult Services (CBAS), In-Home Supportive Services (IHSS).

There are several ways to apply for Medi-Cal:

• With an eligibility worker at Santa Clara County Social Services Agency
• Through MyBenefits CalWIN
• Through Covered California

Please allow 30-45 days to process a Medi-Cal application that does not involve a disability. If you are applying for Medi-Cal based on a disability, your application process may take up to 90 days. It depends on how quickly you complete all the information and when your doctors and hospitals submit your medical records. If you have an immediate medical or dental need, such as pregnancy or a severe illness, be sure to include it on your application. This way, your application may be processed faster.

If you qualify for no-cost Medi-Cal, you will receive Medi-Cal services at no cost to you. If you qualify for share of cost (SOC) Medi-Cal, you will pay a certain amount only in the month you have medical expenses. The amount of your share of cost depends on your income and resources. Each month you will pay your own medical bills until the amount that you have paid equals your share of cost. After that, your care will be covered by Medi-Cal. You will not be covered by Medi-Cal until you have paid your entire share of cost for the month.

Some services are contracted directly with healthcare providers to deliver covered Medi-Cal services. In these cases, you may choose a doctor, dentist, or other provider, who accepts Medi-Cal payments for each service he/she provides at the Medi-Cal payment rate. The provider bills Medi-Cal for services through an entity known as the fiscal intermediary, which is under contract with the California Department of Health Care Services (DHCS) to process Medi-Cal claims and issue reimbursement.

There are two ways to get a new SCFHP ID card:

• Login to the mySCFHP member portal and request a new ID card
• Call Customer Service at 1-800-260-2055 (TTY:711) to ask for a new one

Call Customer Service to update your contact information.

You also need to call the Santa Clara County Social Services Agency and Social Security Administration to change your address.

Santa Clara County Social Service Agency

• Call 1-877-962-3633, Monday through Friday, 8 a.m. to 5 p.m.
• Visit www.mybenefitscalwin.org to find a local field office or for more information.

Social Security Administration

• Call 1-800-772-1213, Monday through Friday, 7 a.m. to 7 p.m. TTY: 1-800-325-0778 or​ 711
• Visit a local field office: www.ssa.gov/agency/contact
• Visit the website: www.ssa.gov/myaccount

There are several ways to change your PCP:

• Login to the mySCFHP member portal to request the change.
• Call Customer Service at 1-800-260-2055 (TTY: 711) to change your PCP.

If we can make the change you want, then in most cases the change to your new PCP will be effective the first day of the next month. For example, if you ask to change your PCP in February, in most cases, you will be able to visit your new PCP on March 1.

Each time you change your PCP, we will mail you a new SCFHP member ID card within two weeks. The new ID card will have your new PCP printed on it.

Providers in SCFHP's Kaiser network and Palo Alto Medical Foundation (PAMF) network are not accepting new Medi-Cal patients. You may be able to select a primary care provider (PCP) in these networks if you meet the following requirements:

• Have continuity of care medical needs, or
• Have been a Kaiser member within the last six months, or
• Received care from a PAMF PCP within the last 24 months, or
• Have an immediate family member living in the same household who is receiving care from Kaiser or PAMF.

How to choose Kaiser:

Call SCFHP Customer Service at 1-800-260-2055 (TTY: 711). Even if you selected Kaiser when you enrolled in Medi-Cal and completed your choice packet, you will need to call SCFHP Customer Service. SCFHP will check with Kaiser to see if you meet the criteria. If your selection of Kaiser is approved, the change is effective on the first day of the following month. If your choice of Kaiser is not approved, we cannot guarantee that services provided by Kaiser will be covered, even if Kaiser agrees to see you for an appointment.

How to choose a Palo Alto Medical Foundation (PAMF) PCP:

If you selected a Palo Alto Medical Foundation PCP when you enrolled in Medi-Cal and completed your choice packet, we will check to see if you meet the criteria. If you do, your Palo Alto Medical Foundation coverage will start the first day of the following month. You will get an SCFHP ID card in the mail with your PCP’s information on it.

You can also call SCFHP Customer Service at 1-800-260-2055 (TTY: 711) to request a Palo Alto Medical Foundation PCP. Please note that if your selection is approved by Palo Alto Medical Foundation, the change is effective on the first day of the following month. If your choice of Palo Alto Medical Foundation is not approved, we cannot guarantee that services provided by Palo Alto Medical Foundation will be covered, even if Palo Alto Medical Foundation agrees to see you for an appointment.

If you get a bill for a covered service, do not pay it. Call us right away at 1-800-260-2055 (TTY: 711). Make sure to have the bill with you. We will need:

• The member's name and address
• The member's identification number on the member ID card
• The date and reason for the bill
• The name of the doctor or hospital
• The amount of the bill

To avoid getting billed by mistake in the future, be sure to always carry your SCFHP member ID card with you to every doctor's visit and when you visit the pharmacy.

You may need to 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. If you have paid the bill, send us the proof of payment.

Send all of the above information to:

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

You need to send this information within 90 calendar days of the date of service. If you have paid the bill, the proof of payment must be acceptable to SCFHP.

Note: If you receive bills for the services below, please do not send them to SCFHP. These services are covered through other programs. You can contact the numbers listed below for payment information:

• For AFP (Alpha Fetal Protein) screenings, call the Extended AFP Program at 1-866-718-7915.
• For mental health services, call ACCESS at 1-800-491-9099.

If you have questions, call SCFHP Customer Service at 1-800-260-2055 (TTY 711).

The SCFHP Medi-Cal Member Handbook has detailed information about SCFHP's Medi-Cal Managed Care plan. The Member Handbook has information on benefits and services, exclusions, limitations, and how to receive benefits and services. You can find the Member Handbook in your language on the Medi-Cal forms & documents page of this website.

The first thing you should do is talk with your primary care provider (PCP). Your PCP will decide whether you need a referral to an SCFHP specialist or an authorization for specialists outside of the SCFHP network.

For non-urgent specialist referrals, please make it a priority to talk to your doctor before the matter becomes urgent.

Behavioral health services covered by Medi-Cal are provided through SCFHP plan providers and the County of Santa Clara. Your primary care provider (PCP) may provide services to treat mild to moderate mental health conditions. You can get specialty mental health services from Santa Clara County Behavioral Health Services.

To get services, contact your PCP or call the Santa Clara County Behavioral Health Call Center at the following numbers:

• For Mental Health Services, call 1-800-704-0900.
• For Substance Use Services, call 1-800-488-9919.
• For the Suicide and Crisis Hotline, call 24/7 at 988.

If you have questions, please call SCFHP Customer Service at 1-800-260-2055 (TTY: 711).

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

If you or your child are enrolled in a Medi-Cal managed care plan, you can choose another Medi-Cal managed care plan at any time. Call Health Care Options (HCO) toll-free at 1-800-430-4263, 8 a.m. to 5 p.m., Monday through Friday. HCO can help you enroll in a new plan.

You can also complete an Enrollment Choice Form and mail it to HCO’s mailing address:

Department of Health Care Services
Health Care Options
P.O. Box 989009
West Sacramento, CA 95798-9850

When HCO receives your call or form, HCO will send you a letter within 15 to 45 days telling you that the health plan change has taken place. You must see your present doctor until you get the letter from HCO.

We try to make it as easy as possible for you to keep your coverage and submit your redetermination forms every year. Follow these three steps to make sure your healthcare coverage is not interrupted:

1. Let us know if you move or if your phone number changes. Call County of Santa Clara Social Services Agency to let us know. The County of Santa Clara Social Services Agency's telephone number is:1-877-962-3633.
2. Watch for a renewal letter in the mail. This letter will ask you to fill out a renewal form. The letter may come from Medi-Cal or Santa Clara Family Health Plan.
3. Fill out the renewal form and return it as soon as possible.

If your Medi-Cal benefits are on hold, you should contact the Santa Clara County Social Services Agency (SSA) to talk to your eligibility worker. The eligibility worker will inform you if your benefits can be reinstated.

If you do not know how to reach your eligibility worker, you can call or visit the SSA office in your area:

Assistance Application Center
Phone: 1-408-758-3800 or 1-877-962-3633
Address: 1867 Senter Road, San Jose, CA 95112

North County Office
Phone: 1-650-988-6200
Address: 1330 W Middlefield Road, Mountain View, CA 94043

South County Office
Phone: 1-408-758-3300
Address: 379 Tomkins Court, Gilroy, CA 95020

General Assistance Services
Phone: 1-408-793-8900
Address: 1919 Senter Road, San Jose, CA 95112

Children's Health Initiative
Phone: 1-888-244-5222

Source: www.sccgov.org

In case of emergency, call 911 or go to the nearest emergency room.

Santa Clara Family Health Plan Medi-Cal 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.

An advance healthcare directive is a form you fill out before you are no longer able to make decisions for yourself because of an illness or any unexpected life situation. This form is a way to make your healthcare wishes known if you are unable to speak for yourself or if you prefer someone else speak for you. The directive explains the types of treatment you want or do not want. It also allows you to name a person to be your healthcare agent. This person can be a spouse, family member, friend, or someone else. This person can make decisions for you if you can no longer make them for yourself. Your rights as a member of SCFHP apply to your chosen healthcare agent.

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

You may call Customer Service at 1-800-260-2055 (TTY: 711) for help setting up and using an advance healthcare directive. Get more information about advance care directives and download a form here.

You can give legal permission to have someone represent you. You can choose a relative, friend, or other trusted person to act on your behalf to contact SCFHP with questions, or to make a complaint or appeal a coverage decision.

A personal representative is authorized to discuss or disclose your protected health information and other benefit information with SCFHP. To appoint a personal representative, complete an Authorized Representative Form.

• Authorized Representative Form—English
• Authorized Representative Form—Español
• Authorized Representative Form—Tiếng Việt
• Authorized Representative Form—中文
• Authorized Representative Form—Tagalog

Send the completed Authorized Representative Form to:

• Mail:
  Attn: Customer Service
  Santa Clara Family Health Plan
  PO Box 18880
  San Jose, CA 95158
• Fax:
  1-408-874-1965

If you have any questions, please call Customer Service at 1-800-260-2055 (TTY: 711).

When you first enroll in SCFHP, if you have been receiving care from a non-plan provider, such as a hospital, you may be able to continue that care for a period of up to 12 months for primary and specialty services, if all the following are true:

1. You have an ongoing relationship with the non-plan provider, prior to enrollment in SCFHP.
2. The non-plan provider is willing to work with SCFHP and agrees to SCFHP requirements.
3. You were seen by the non-plan provider at least once during the twelve (12) months prior to your enrollment with SCFHP for a non-emergency visit.
4. You were seen by the non-plan provider at least once during the six (6) months prior to the transition of services from a Regional Center to SCFHP.
5. SCFHP does not have a documented quality of care concern with the non-plan provider.

If a provider do not join an SCFHP network by the end of 12 months, do not agree to SCFHP payment rates or do not meet quality of care requirements, you will need to switch to providers in an SCFHP network or call Customer Service at 1-800-260-2055 (TTY: 711) to discuss your options.

If you are being treated by a provider for certain health conditions who is not an SCFHP provider or your provider stops working with SCFHP, you may be able to keep getting services from that provider. This is another form of continuity of care. Services SCFHP provides for continuity of care include but are not limited to:

• Acute conditions (a medical issue that needs fast attention) – for as long as the condition lasts.
• Chronic physical and behavioral conditions (a medical issue you have for a long time) – for an amount of time required to finish the course of treatment and to arrange for a safe transfer to a new doctor in your SCFHP
• Pregnancy – during the pregnancy and the immediate postpartum period.
• Maternal mental health services
• Care of a newborn child between birth and age 36 months for up to 12 months from the start date of the coverage or the date the provider’s contract ends with SCFHP.
• Terminal illness (a life threatening medical issue) – for as long as the illness lasts. Completion of covered services may exceed twelve (12) months from the time the provider stops working with SCFHP.
• Performance of a surgery or other medical procedure from a non-plan provider as long as it is covered, medically necessary and is authorized by SCFHP as part of a documented course of treatment and has been recommended and documented by the provider – surgery or other medical procedure to take place within 180 days of the provider’s contract termination date or 180 days from the effective date of coverage of a new member.

For other conditions that may qualify, contact SCFHP Customer Service at 1-800-260-2055 (TTY: 711).

If the non-plan provider is not willing to continue to provide services, does not agree on payment or other terms for providing care, then you will not be able to receive continued care from the provider. Call Customer Service at 1-800-260-2055 (TTY: 711) for help selecting a contracted provider to continue with your care or if you have any questions or problems in receiving covered services from a provider who is no longer part of SCFHP.

SCFHP is not required to provide continuity of care for services not covered by Medi-Cal, durable medical equipment, transportation, other ancillary services and carved-out service providers. To learn more about continuity of care and eligibility qualifications, and to hear about all available services, call Customer Service.

If a provider's contract is ended, SCFHP will notify you. The notice will tell you the name and contact information for a new provider that will continue your care. Remember, you can change your primary care provider (PCP) at any time. Here's how you can choose a new PCP:

• Log in to the mySCFHP member portal and use the tool to find a new PCP. Then complete and submit a form to change your PCP to a new one.
• Call Customer Service at 1-800-260-2055(TTY:711).

The notice will also tell you what to do if you want to continue to see your current provider. You must tell us that you want the provider (physician, medical group, or hospital) providing healthcare services to continue to provide and complete the services.

As a SCFHP member, you have access to classes and printed information to help you manage your health. Please visit our Health Education page to see a general list of classes and services. Log in to the mySCFHP member portal and use the Health Education Referral Form to sign up for classes available to you.

If you are a new SCFHP Medi-Cal member, you will receive a Health Information Form (HIF) in the mail with your welcome packet. Filling out the form is voluntary. It will help us better support your health needs. You will not be denied care based on your confidential answers.

If you have questions about completing the HIF, please call Customer Service at 1-800-260-2055 (TTY: 711), Monday through Friday, 8:30 a.m. to 5:00 p.m.

Please return the completed form(s) in the postage-paid envelope provided in your welcome packet. Or, mail it to:

Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Download the HIF

As a member of SCFHP, you have certain rights and responsibilities. Rights are what you can expect to receive, including needed treatment and information. Responsibilities are what we expect you to do as an SCFHP member. You can find a full list of your rights and responsibility as an SCFHP member in Chapter 7 of your Medi-Cal Member Handbook.

Nurse Advice Line

It can be hard to know what kind of care is needed. That's why our nurse advice line has qualified health professionals here to help 24 hours a day, 7 days a week. Call the SCFHP Nurse Advice Line at 1-877-509-0294 to:

• Talk to a nurse who will answer medical questions, give care advice, and help you decide if you should see a provider right away.
• Get help with medical conditions such as diabetes or asthma, including advice about what kind of provider may be right for your condition.

Be prepared to answer a few questions and give as much detail as you can.

This service is free for SCFHP members.

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

Urgent care—Nights and weekends

Urgent care is not for an emergency or life-threatening condition. It is for services you need to prevent serious damage to your health from a sudden illness, injury or complication of a condition you already have. Urgent medical problems are problems that usually need attention within 24 to 48 hours.

If you think you have an urgent medical problem, call your PCP's office—even if the office is closed. If you cannot reach your PCP, call Nurse Advice Line at 1-877-509-0294.

We recognize the importance of maintaining the confidentiality of all members' medical record information and personal identification. All such information will be held confidential by SCFHP and its contracting providers.

We will not use any member's confidential information for any purpose other than:

• Carrying out the express terms of our contract with the Department of Health Care Services.
• As otherwise permitted or required by our contract with the Department of Health Care Services.
• As permitted by any applicable state or federal law.
• As permitted with the member's written consent, when consent is required by applicable law.

A statement describing our policies and procedures for preserving the confidentiality of medical records and personal identifying information is available in our Notice of Privacy Practices.

We are taking steps to protect the privacy of our members receiving sensitive care services. SCFHP will only send your information related to sensitive services to you. For a list of sensitive care services, look at Chapter 3 of your Medi-Cal Member Handbook.

You may also ask that we:

• Send the sensitive service information to another address
• Share the sensitive service information in another format, such as email or phone

If you want to make a confidential request about your sensitive care services, call SCFHP Customer Service at 1-800-260-2055 (TTY: 711). You can also mail the request to
PO Box 18880 San Jose, CA 95158.

Remember to also talk to your provider about your communication preference for sensitive care services.

SCFHP asks our new and current members to complete the Staying Healthy Assessment (SHA). The SHA is a set of questions that allows your doctor to understand your health and help you decide what types of services you need.

Based on your age, the form asks questions on topics such as the types of food you eat, how much you exercise, and if you smoke. Some of the questions may be personal. You don't have to answer any questions if you don't want to. If you choose to answer a question, be honest and as complete as possible.

It should only take a few minutes to fill out the form. You may fill out an SHA at your doctor's office or fill out the form at home and take it with you to your appointment. You (or your child) do not have to be sick to schedule this doctor visit.

You can print out the SHA form in your preferred language from the Department of Health Care Services website.

Your responses are confidential. The completed SHA will be kept in your medical record.

New members

Within the first four months of becoming a member, schedule an appointment with your doctor to complete the SHA. You (or your child) do not have to be sick to schedule this doctor visit.

Current members

If you are a current member and have not completed an SHA, or have not completed one recently, please schedule a preventive care visit and complete the SHA as part of that visit.

Newborns, toddlers, kids, and teen members

Parents with children under 18 years of age should complete an SHA for your child on the first scheduled doctor visit. Parents should complete it again when your child reaches a new SHA age group. The SHA Periodicity Table below shows the SHA age groups.

Adult and senior members

Adult and senior members (18 years of age and older) should complete a new SHA every three to five years.

SHA Periodicity Table

SHA Refusal

As a member, you have the right to refuse, decline, or skip any or all parts of the SHA. Your doctor will ask you to sign the refusal document, and it will be kept in your medical record.

If you have any questions about the SHA, call your doctor or SCFHP Customer Service at 1-800-260-2055 (TTY:711).

If you have no way of getting to and from a non-emergency medical appointment, we can help. The appointment must be for services covered by your health plan.

We provide transportation based on:

• Your medical and physical condition
• The urgency of the appointment
• Availability of transportation at the time needed

To request transportation, log in to the mySCFHP member portal and submit your request.

• Request nonemergency medical transportation: This form is used to request nonemergency medical transportation (NEMT) to a scheduled medical appointment. You need your doctor to first complete the Physician Certification Statement (PCS) form to request the type of transportation you need. SCFHP needs this form for pre-approval (prior authorization) before arranging NEMT services. If your doctor already completed the PCS form, be sure to submit your request five business days before your scheduled medical appointment. SCFHP Customer Service will contact you to confirm your request.
• Request a taxi: This form is used to request a taxi to a scheduled medical appointment. You need to submit your request three business days before your scheduled medical appointment. SCFHP Customer Service will contact you to confirm your request.

Visit our Transportation services page to learn more.

If you are a Kaiser member, contact Kaiser's Member Services to request transportation.

If you think you're having a medical or psychiatric emergency, call 911 or go to the nearest hospital.

SCFHP covers eye screenings and eye exams for all Medi-Cal members through Vision Service Plan (VSP).

To find a VSP provider near you:

• Use our Find a Doctor tool
• See the VSP Provider Directory
• Visit VSP's website, vsp.com
• Call VSP Member Services at 1-800-877-7195, Monday through Friday, 5 a.m. to 8 p.m., Saturday and Sunday, 7 a.m. to 8 p.m.
• Email VSP Member Services

Members who have trouble hearing can call 1-800-428-4833 for help.

Medi-Cal covers some dental services, including:

• Diagnostic and preventive dental hygiene (such as examinations, X-rays and teeth cleanings)
• Emergency services for pain control
• Tooth extractions
• Fillings
• Root canal treatments (anterior/posterior)
• Crowns (prefabricated/laboratory)
• Scaling and root planning
• Periodontal maintenance
• Complete and partial dentures
• Orthodontics for children who qualify

If you have questions or want to learn more about dental services, call Smile California at 1-800-322-6384 (TTY 1-800-735-2922). You may also visit the website at smilecalifornia.org.