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Medi-Cal Frequently Asked Questions

Frequently asked questions for people looking to enroll into the SCFHP Medi-Cal program

Am I eligible for Medi-Cal?

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 U.S. citizen or Legal Permanent Resident
  • A member of a family whose income falls within the Medi-Cal eligibility guidelines

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

  • Live in California
  • Are younger than 26 years old
  • Have a family income no higher than 266 percent of the Federal Poverty Level

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)
  • Refugee Assistance
  • Foster Care or Adoption Assistance Program

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

What if I currently have insurance, but would like to switch to Medi-Cal?

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

If I am pregnant, can I apply for my child before he/she is born?

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

How much does Medi-Cal cost?

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.

What does Medi-Cal cover?

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
  • 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 Denti-Cal)
  • 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) and Multipurpose Senior Services Program (MSSP).

How do I apply for Medi-Cal?

There are several ways to apply for Medi-Cal:

How soon can I get Medi-Cal?

30-45 days are allowed 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.

What is the difference between no-cost Medi-Cal and share of cost Medi-Cal?

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 SCFHP for that month. You will not be covered by SCFHP until you have paid your entire share of cost for the month. After you meet your share of cost for the month, you can go to your PCP and other providers in your network. If you do not have a PCP, call SCFHP Customer Service.

What is Medi-Cal Fee-For-Service (FFS)?

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.

Frequently asked questions for SCFHP Medi-Cal members

I lost my Member ID Card. How do I get a new one?

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

How do I change my address?

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

 

Social Security Administration

How do I change my primary care provider (PCP)?

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 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.

I would like to go to Kaiser or Palo Alto Medical Foundation. How does this process work?

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. Please note that 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.

What happens if I receive a bill?

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 Customer Service at 1-800-260-2055 (TTY 711).

Where can I find latest information on my covered benefits?

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.

What do I need to do in order to see a specialist?

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 point to talk to your doctor before the matter becomes urgent.

How do I get behavioral health services?

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:

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.

How can I change to a different Medi-Cal managed care health plan for myself or my child?

If you or your child are enrolled in a Medi-Cal managed care plan and want to choose another Medi-Cal managed care plan, you can 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.

How do I make sure I renew my SCFHP Medi-Cal coverage?

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

  1. 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.
  2. Fill out the renewal form and return it as soon as possible.
  3. 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.

I have been informed that my Medi-Cal benefits are on hold. What should I do?

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

What should I do if I have a medical emergency?

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.

Important things and words to know as an SCFHP Medi-Cal members

We want to make sure you get the most out of Medi-Cal. Please read this page carefully to learn how to access all of the services and benefits your health plan has to offer.

If you have any questions or need more information, please call Customer Service at 1-800-260-2055. TTY users should call 711.

Advance healthcare directives

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 used to tell your healthcare provider, family, and friends about the healthcare you want if you can no longer make decisions for yourself. 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 for help setting up and using an advance healthcare directive. You can download an advance healthcare directive form here.

Appointing a personal representative

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.

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.

Continuity of care (continuing treatment with your current provider)

When you first enroll in SCFHP, if you have been receiving care from a nonplan 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 criteria are met:

  1. The member demonstrates an existing relationship with the provider prior to enrollment in the Plan (nonemergency visit in prior 12 months).
  2. The provider is willing to accept reimbursement from SCFHP based on the current SCFHP rate for the service offered or applicable Medi-Cal fee schedule, whichever is higher; and
  3. SCFHP does not otherwise exclude the provider from the provider network due to documented quality of care concerns.

If a provider stops working with SCFHP, and that provider, including a plan hospital, has been caring for you for a service that SCFHP covers, we will help you continue to get or complete your medical care. You may continue such care under the following conditions:

  • You ask SCFHP to help you by calling Customer Service, and
  • The nonplan provider agrees to SCFHP's requirements, and
  • The care is for one of the conditions listed below and is a covered benefit.

SCFHP may also transfer care to an in-plan provider to make sure your care is not interrupted.

There are specific conditions where we will cover your medical care with a nonplan provider.  This list tells you which conditions are eligible and for how long:

  • An acute condition: SCFHP will help you continue getting care for a covered service until you no longer have the acute condition.
  • Serious chronic condition: SCFHP will help you continue getting care for a covered service for as long as it takes for your treatment of the serious chronic condition to be complete. After your treatment is completed, we will transfer your care to an in-plan provider.
  • We will help you:
    • Get a surgery or other medical procedure from the nonplan provider as long as it is a covered service, medically necessary, and has already been approved as part of a documented treatment plan.
    • Continue getting care that is a covered service for a newborn child between birth and 36 months, for up to 12 months from the effective date of coverage.
    • Continue getting care that is a covered service for a pregnancy, including postpartum care. Postpartum is up to six weeks after delivery.
    • Continue getting care that is a covered service for the duration of a terminal illness.

 

Note: If you are a new member who is already receiving treatment or services for a complex medical condition, including pregnancy, you may prefer to stay in the Medi-Cal Fee-For-Service Program. If so, you or your healthcare provider may call Health Care Options at 1-800-430-4263.

You can ask Health Care Options for a "medical exemption." This means that you will be exempt from joining a managed care plan. But you must show Health Care Options that you qualify for the program. To qualify, you must prove that you have a "complex medical condition" and need to continue care with the healthcare provider you are seeing.

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.

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.

If the provider and SCFHP cannot agree on payment or other terms for providing care, then SCFHP does not have to pay for the services. In this case, if you still want the services, then you will be responsible for paying the provider.

Health education

As a 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.

Health information form for new members

If you are a new SCFHP Medi-Cal member, you will receive a Health Information Form (HIF) in the mail. 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 to:

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

Download the HIF

Member rights and responsibilities

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 on our Member rights and responsibilities page of this website. 

Nurse Advice Line, Urgent Care, and After Hours Care

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. Here are some of the ways they can help you:

  • Decide whether to go to the emergency room or urgent care or wait for an appointment with your doctor
  • Care for the problem at home, if appropriate

You can call the nurse advice line to speak to a qualified health professional day or night. Call 1-877-509-0294.

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

Some medical problems may require urgent care but are not emergencies. 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 primary care provider's office—even if the office is closed. Your doctor, or the on-call physician, is always available 24 hours a day, 7 days a week, to help if there is an urgent medical problem and will tell you what to do.

Privacy—medical and personal records

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

Staying Healthy Assessment (SHA)—When you need to complete the SHA

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

Age Groups Administer Within 120 Days of Enrollment Re-administer 1st Scheduled Exam (after entering new age group) Re-administer Every 3-5 years Review Annually (Interval Years)
0-6 mo.      
7-12 mo.    
1-2 yrs.  
3-4 yrs.  
5-8 yrs.  
9-11 yrs.  
12-17 yrs.  
Adult  
Senior  

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.

Transportation Needs

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.

Vision Care Services

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

To find a VSP provider near you:

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

Dental Services

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 Denti-Cal at 1-800-322-6384 (TTY 1-800-735-2922). You may also visit the Denti-Cal website at denti-cal.ca.gov.