Medi-Cal Frequently Asked Questions
Frequently asked questions
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 U.S. citizen or Legal Permanent Resident
- A member of a family whose income falls within the Medi-Cal eligibility guidelines
Children are eligible, regardless of immigration status, if they:
- Live in California
- Are younger than 19 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.
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 the Evidence of Coverage (EOC) for detailed information about SCFHP's Medi-Cal Managed Care plan. The EOC 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
- 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:
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. 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.
If you have questions, call Customer Service at 1-800-260-2055.
Program and benefit change annoucements
Below you will find updates to the Medi-Cal program and your benefits and services covered by SCFHP. Check this page periodically for updates to your Medi-Cal benefits.
Effective Jan. 1, 2018
If you are an adult Medi-Cal member, your dental benefits will change. More services are available to you starting Jan. 1, 2018. Added services include:
- More types of exams
- Deep cleanings (scaling and root planing)
- Laboratory crowns
- Partial dentures
- Root canals in back teeth
- Medically necessary dental services can go over the yearly $1800 limit.
If you are pregnant, in a skilled nursing or intermediate care facility, or a child, your dental benefits will not change.
Questions? Call Denti-Cal at 1-800-322-6284.
Effective Jan. 1, 2015
If you have Medi-Cal AND Medicare:
You have a new healthcare option called Cal MediConnect. Cal MediConnect is a voluntary program that coordinates all the services and benefits you currently receive through Medicare and Medi-Cal, including Long-Term Services and Supports (LTSS), under one health plan. Additional benefits include a care manager and a care team, if needed, and transportation and vision. Learn more about the Cal MediConnect program.
Effective Sept. 15, 2014
Santa Clara Family Health Plan covers behavioral health treatment (BHT) for autism spectrum disorder (ASD). BHT includes applied behavior analysis and other services, such as occupational or speech therapy. The services may help you or your child with ASD to function better and lead a healthier, fuller life.
BHT services must be:
- Medically necessary; and
- Prescribed by a licensed doctor or a licensed psychologist; and
- Approved by SCFHP; and
- Given in a way that follows the member’s SCFHP-approved treatment plan.
You may qualify for BHT services if:
- You are under 21 years of age; and
- Have a diagnosis of ASD; and
- Have behaviors that interfere with home or community life. Some examples include anger; violence; self-injury; running away; or difficulty with living skills, play, and/or communication skills.
You do not qualify for BHT services if you:
- Are not medically stable; or
- Need 24-hour medical or nursing services; or
- Have an intellectual disability (ICF/ID) and need procedures done in a hospital or an intermediate care facility.
If you are currently receiving BHT services through the Regional Center, the Regional Center will continue to provide these services for now. More information will be available when it is time to transition to SCFHP for these services.
You can call SCFHP if you have any questions or ask your primary care provider for screening, diagnosis, and treatment of ASD. You can reach our Member Services Department Monday through Friday from 8:30 a.m. and 5:00 p.m. at 1-800-260-2055. TTY is 1-800-735-2929.
There is no cost to the member for these services.
For a pdf of this notice, click on the language you want:
Effective July 1, 2014
Your Medi-Cal benefits now include Long-Term Services and Supports (LTSS). SCFHP is responsible for working with your providers to coordinate all of your Medi-Cal benefits, including LTSS.
What are Medi-Cal Long-Term Services and Supports or LTSS?
- In-Home Supportive Services (IHSS). These are personal care services for people who need help to live safely in their homes.
- Community-Based Adult Services (CBAS). This is daytime healthcare at centers that provide nursing care, therapy, activities, and meals for people with certain chronic health conditions.
- Multipurpose Senior Services Program (MSSP). This provides social and healthcare coordination services for people age 65 and older.
- Long-Term Care (LTC) or Nursing Facility Care. If you get care in a nursing facility, SCFHP will work with your doctor and nursing facility to give you the same services you get now and to better coordinate your care. If you are currently in a nursing home, you do not have to change your nursing home.
Why are these changes happening?
Many people with Medi-Cal get their healthcare and LTSS from different providers who do not always work together. California’s Coordinated Care Initiative brings your healthcare and LTSS into one managed care health plan so your benefits and services work together better. These changes should make it easier for you to get the care and services you need while helping you continue to live independently in your home and community.
Effective Jan. 21, 2014
SCFHP now covers some of your mental health services and substance use disorder services that you used to get in regular Medi-Cal.
What does this mean for your mental health services?
You do not need to do anything. You will receive the following mental health services through SCFHP:
- Individual and group mental health testing and treatment (psychotherapy)
- Psychological testing to evaluate a mental health condition
- Outpatient services that include lab work, drugs, and supplies
- Outpatient services to monitor drug therapy
- Psychiatric consultation
What does this mean for substance use disorder preventive services?
Alcohol misuse screening services are now a covered benefit by SCFHP for all members 18 and older. The services covered for alcohol misuse are called Screening, Brief Intervention, and Referral to Treatment (SBIRT) and include:
- One expanded screening for risky alcohol use per year; and
- Three 15-minute brief intervention sessions to address risky alcohol use per year.
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.
- 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:
Attn: Customer Service
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
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:
- The member demonstrates an existing relationship with the provider prior to enrollment in the Plan (nonemergency visit in prior 12 months).
- 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
- 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.
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
Member rights and responsibilities
As an SCFHP Member, you have the right to:
- Be treated with respect and courtesy regardless of your gender, culture, language, appearance, sexual orientation, race, disability, or source of payment.
- Be told in a clear way about all healthcare services available and how to get them.
- Receive written member materials in English, Spanish, or Vietnamese (depending on the plan you are enrolled in) or alternative formats, including Braille, large print and audio format upon request.
- Select a healthcare provider or clinic as your primary care provider (PCP). Your PCP will provide or arrange for all the healthcare you need.
- Receive needed and appropriate medical care, including preventive health services and health education.
- Access family planning services, Federally Qualified Health Centers, Indian Health Services facilities, sexually transmitted disease services, and emergency services outside of the SCFHP network according to federal law.
- Access minor consent services.
- Know and understand your medical condition as diagnosed by your healthcare provider, know what the healthcare provider plans to do to treat the condition, know what results you can expect, and know what effects the treatment may have on your daily life.
- Actively take part in decisions about your medical care. If permitted by law, you have the right to refuse or stop treatment.
- Formulate advanced directives.
- Have the meaning and limits of confidentiality explained to you.
- Have your health records kept confidential, except when disclosure is required by law or permitted in writing by you. With adequate notice, you have the right to see your Protected Health Information (PHI), as allowed by law.
- Know that if you must be moved or transferred from one hospital to another, you may receive information about why you need to be moved and about any other choices you may have.
- Receive a second opinion from another plan physician about your diagnosis, the proposed plan of treatment, and other available options.
- Know how to get help and solve problems; know how to file a grievance or appeal with SCFHP; know how to ask for a State Fair Hearing. Understand how to use the grievance or State Fair Hearing process without fear of interruption or loss of healthcare, or risk of retaliation.
- Take part in establishing SCFHP's public policy, by attending or joining the SCFHP Consumer Advisory Committee and attending any SCFHP Governing Board meeting.
- Have an interpreter who speaks your language (including Sign Language) available 24 hours a day, 7 days a week, at no cost to you.
- File a grievance if your cultural and linguistic needs are not met.
- Disenroll from SCFHP.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- Freedom to exercise these rights without adversely affecting how you are treated by SCFHP, plan providers, or the State.
American Indians and Alaska Natives (AIANs) have the right to choose to receive primary care services at Indian Health Service Facilities or Federally Qualified Health Centers (FQHCs) or from any other plan provider within SCFHP's geographic service area (Santa Clara County). AIANs also have the right to stay in regular Medi‑Cal and not enroll in a managed care plan.
As an SCFHP Member, you have the responsibility to:
- Carefully read all SCFHP materials as soon as you enroll so you understand how to use our services.
- Ask questions when you do not understand something about your coverage or medical care.
- Follow the rules of SCFHP membership as explained in your plan's Evidence of Coverage document.
- Be responsible for your own health and the health of your children.
- Talk to your healthcare provider so you can develop a strong relationship based on trust and cooperation.
- Call your healthcare provider when you need routine or urgent healthcare.
- Report unexpected changes in your health to your PCP.
- Ask questions about your medical condition. Make sure you understand the answers, and what you are supposed to do.
- Follow the treatment plan your healthcare provider gives you, and know what might happen if you do not follow the treatment plan.
- Make and be on time for medical appointments. Let your healthcare provider know at least 24 hours before your scheduled appointment if you need to cancel.
- Tell SCFHP about any changes in: address; phone number; family status, such as marriage, divorce, etc.; and changes in any other healthcare coverage you might have. Tell us about these changes as soon as you know them or within 10 days of these changes.
- Call or write SCFHP as soon as possible if you feel you were improperly billed or if the bill is wrong.
- Treat all SCFHP personnel and healthcare providers with respect and courtesy.
- Submit requests for claims reimbursement for covered services within the required time period.
Be honest in your dealings with SCFHP and its plan providers. Do not commit fraud or theft or do anything that threatens the property of SCFHP or the property or safety of any of its representatives, plan providers, plan providers' employees, or agents.
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.
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.
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:
- 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.
- Fill out the renewal form and return it as soon as possible.
- 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.
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 English, Spanish, Vietnamese, Chinese, and Tagalog from the Member Forms & Documents page.
Your responses are confidential. The completed SHA will be kept in your medical record.
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.
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)|
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.
Example Staying Healthy Assessment Form
This is an example of a Staying Healthy Assessment form:
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.
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:
- 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.