Benefits & Copays
Benefits & Copays
Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan 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), which consists of Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP) and Nursing Facilities (NF)
You can find a description of the 2018 benefits and copays in the sections below.
For more information, call SCFHP Cal MediConnect Customer Service or read the SCFHP Cal MediConnect Member Handbook and Summary of Benefits.
SCFHP Cal MediConnect provides all services covered by Medicare and Medi-Cal. Benefits include:
- Doctor visits*
- Lab tests, x-rays, or other medical tests*
- Prescription and over-the-counter drugs*
- Occupational, physical, or speech therapy*
- Emergency services, including ambulance
- Urgent Care
- Hospital stay*
- Skilled nursing care*
- Vision care: one routine exam every year and up to $100 every two years for contact lenses or eyeglasses (frames and lenses). Benefits are provided through VSP.
- Behavioral health services (mental health and substance abuse treatment)*
- Durable medical equipment*
- Hearing services, including hearing aids, up to $1,510 maximum allowed per member for both ears per fiscal year (July 1 – June 30)*
- Chiropractic services*
- Dental care (You must get covered dental services through Denti-Cal. These services are a limited benefit. Contact the Denti-Cal toll free beneficiary line at 1-800-322-6384 for more information about covered dental care or go to www.denti-cal.ca.gov.)
- Transportation services: non-emergency medical transportation and non-medical transportation*
- Long-term services and supports (LTSS), including Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP) and Nursing Facilities (NF)*. LTSS is not a benefit for SCFHP Cal MediConnect members outside of Santa Clara County Service Area.
* Prior authorization may be required.
Ask us to make a coverage decision. A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.
To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.
You can call us at: 1-877-723-4795. TTY/TDD: 1-800-735-2929 or 711.
You can fax us at: 1-408-874-1957.
You can write to us at:
Attn: Utilization Management
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
How long does it take to get a coverage decision?
It usually takes up to 14 calendar days after you asked. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. The letter will explain why more time is needed. If we do not give you our decision within 14 calendar days (or within 28 calendar days if we need more time), you can appeal.
Can I get a coverage decision faster?
Yes. If you need a response faster because of risk to your health, ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. The letter will explain why more time is needed.
Asking for a fast coverage decision:
- If you request a fast coverage decision, start by calling or faxing our plan to ask us to cover the health services you need.
- You can call us at 1-877-723-4795 (TTY/TDD users should call 1-800-735-2929 or 711), or fax us at 1-408-874-1957.
- You can also have your doctor or your authorized representative call or fax us.
You must meet the following two requirements to get a fast coverage decision:
- You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for care or an item you already got.)
- You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function.
- If your doctor says that you need a fast coverage decision, we will automatically give you one.
- If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.
- If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of a fast coverage decision. (For more information about the process for making complaints, including fast complaints, see Section 10 of your Member Handbook.)
If the coverage decision is Yes, when will I get the service or item?
You will be approved (pre-authorized) to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will approve the coverage by the end of that extended period. After you get approval, you can schedule your service or get the item from your provider.
If the coverage decision is No, how will I find out?
If the answer is No, we will send you a letter telling you our reasons for saying No.
- If we say no, you have the right to ask us to change this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.
- If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. See the section of our website about the appeals process for more information.
You can call us at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711.
SCFHP Cal MediConnect Plan will generally pay for the health care services, behavioral health services, and long-term services and supports you get as long as you are eligible and the criteria below are met. To be covered:
- The care you get must be a plan benefit.
- The care must be determined necessary.
- For medical services, you must have a network primary care provider (PCP) who has ordered the care or has told you to see another doctor. As a plan member, you must choose a network provider to be your PCP.
- You must get your care from network providers, except for limited exceptions.
For detailed information on limitations and restrictions, see the SCFHP Cal MediConnect Member Handbook found in Member Materials.
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 us at 1-877-723-4795 (TTY/TDD users should call 1-800-735-2929 or 711), or fax us at 1-408-874-1957.
You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect by contacting the SCFHP Grievance and Appeals Department:
Toll Free: 1-877-723-4795
TTY/TDD: 1-800-735-2929 or 711
Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
You can ask for published materials for free in other formats, such as large print, braille or audio. Call Customer Service for help.
If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
(8:00 a.m. - 8:00 p.m.
Monday - Friday)
Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays, and restrictions may apply. Benefits and/or copays may change on January 1 of each year.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details.
Last updated 12/29/2017