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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
San Francisco Health Plan
Evidence of Coverage and
Disclosure Form
2009-2010
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Welcome to the San Francisco Health Plan San Francisco Health Plan Location and
San Francisco Health Plan (SFHP) is here Contact Information:
to help you with your health care needs.
San Francisco Health Plan
Let’s work together to keep you in good 201 Third Street, 7th Floor
health. This Handbook will help you San Francisco, CA 94103
understand what services are provided
by SFHP and how to get them. (415) 547-7800 (local)
Please read it carefully. (800) 288-5555 (toll free)
You have the right to review this Handbook
prior to enrollment. If you have special memberservices@sfhp.org
health care needs, pay particular attention
to parts that apply to you. Who Should I Call?
Call San Francisco Health Plan
Some of the words in this Handbook have (SFHP) at (415) 547-7800 (local)
special meanings. Read Section 12, page or (800) 288-5555 (or email us at
62 Important Words You Should Know,” of
memberservices@sfhp.org) to:
the Evidence of Coverage section of this
Handbook to understand how these words • To change your primary care provider
are used. • To get a new member ID card
Information about our providers and • To inform us of a change to your name,
contracted hospitals and other facilities and address, phone number or social
services is included in the Provider security number
Directory.
• If you are unhappy with your provider
Keep in mind: or another health care service
This Combined Evidence of Coverage • If you need help filling your prescriptions
and Disclosure Form constitutes only • To ask questions about getting services
a summary of SFHP policies and coverage or health benefits
under the Medi-Cal Program. The Medi-Cal
Program regulations (Title 22 of the • To talk about a problem or file a
California Code of Regulations, Division 3, complaint
Health Care Services) issued by the State • If you need help with nutrition,
of Department of Health Care Services parenting, breastfeeding, or other topics
(DHCS), should be consulted to determine • To get information about community
the exact terms and conditions resources
of coverage.
• To find out how to get to your
SFHP makes it easy to get health care. primary care provider’s office
This Handbook should answer most of your • To ask any other questions you may
questions about your health care benefits. have
If you want more detailed information, check
the Evidence of Coverage section in this • If your eligibility is put on hold
Handbook. You may also direct questions • If you are cut off from Medi-Cal
concerning your health plan benefits to • If you have medical billing issues with
Member Services at (415) 547-7800 (local) SFHP
or (800) 288-5555 from Monday through
Friday, 8:30am to 5:30pm. • If you want to check eligibility with SFHP
For members of SFHP that are hearing
Information for Members Who Have Trouble
impaired, please call (415) 547-7830 (TDD)
Reading
or (888) 883-7347.
SFHP will get you this Handbook and other
important Plan materials in alternate formats Call the Medi-Cal Program at
like Braille, large size print and audio if you (415) 558-1853 to:
can’t see well, or we can read parts to you • Change your address, phone number,
over the telephone. For alternate formats, or name
or for help in reading SFHP materials,
please call SFHP Member Services at • To correct your social security number
(415) 547-7800 (locally) or (800) 288-5555. Call San Francisco Community Behavioral
Health Services (SFCBHS) at
(415) 255-3737 or (888) 246-3333
(toll free) or (888) 484-7200 (TDD) to:
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Get mental health counseling
• Access a substance abuse counselor
Call Vision Service Plan (VSP) at (800) 438-
4560, for benefits for children under the age
of twenty one (21) or an adult diabetic, age
twenty one (21) and older. Services are not
covered for non-diabetic adults age twenty
(21) and older. Vision coverage is a limited
benefit for certain members only. See page
47, “Medi-Cal Members That Still Have
Optional Benefits” for a description of the
limitations and exceptions.
to:
• Get an eye exam or eyeglasses
Call Denti-Cal at (800) 322-6384, for
children under the age of twenty (21).
Services are not covered for adults age
twenty one (21) and older. Dental coverage
is a limited benefit for certain members only.
See page 47, “Medi-Cal Members That Still
Have Optional Benefits” for a description of
the limitations and exceptions.
to:
• Get information about dental coverage
• Get a list of dentists near you
You may call SFHP with any questions
at (415) 547-7800 (local) or (800) 288-5555.
We are here for you.
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Table of Contents 1. About San Francisco Health Plan
(SFHP) .............................................. 19
A. Quick Guide ......................................... 7
A. Check Your SFHP Member
1. Getting Started .................................... 7 ID Card......................................... 19
2. How to Get Care ............................... 19
About Your SFHP Member Handbook .. 7
How Managed Care Works ................... 7 A. About Your Primary Care
Help in Other languages and for the Provider........................................ 19
Hearing Impaired................................... 7 B. What to Do if Your PCP’s
Your Member ID Card ........................... 7 Office is Closed ............................ 20
C. What to Do If You Are Out
2. Choosing Your Primary Care of the Area ................................... 20
Provider (PCP) ..................................... 8 D. Post-Stabilization and
Follow-up Care After an
What is a Primary Care Provider (PCP)? Emergency .................................. 20
8 E. Changing Your PCP
What Kind of Provider Can Be a PCP? 8 or Medical Group ........................ 21
How Do I Choose a Nurse Practitioner F. Going to the Correct Hospital ...... 21
or Physician’s Assistant As My PCP? ... 8 G. How to See a Specialist ............... 21
Where Do PCPs Work? ........................ 8 H. Getting a Second Opinion............ 21
Your PCP’s Medical Group ................... 9 I. Why Are Initial Health
Choosing Your PCP .............................. 9 Assessments (IHAs) And Check-
Using the Provider Directory ................. 9 Ups Important? ............................ 21
Changing Your PCP .............................. 9 J. Getting Prescriptions Filled .......... 22
Why Can a Provider Request a Change K. Getting Eye Exams and Glasses 22
in Member’s PCP? .............................. 10 L. Getting Dental Exams
and Other Dental Care ................. 22
3. Getting Care Under Your New Health M. Getting Help for Mental
Plan ..................................................... 10 or Emotional Problems ................ 22
Getting Care ........................................ 10 N. Getting Help for Alcohol
Specialty Care ..................................... 10 or Drug Abuse .............................. 22
Family Planning................................... 10 O. If You Have a Disability................ 22
Second Opinions ................................. 11 P. Information for Members
Pharmacy Services ............................. 11 Who Are Hearing Impaired .......... 22
Hospital Care ...................................... 11 Q. Information for Members
Emergency Medical Care .................... 11 Who Speak English as a Second
Urgent Care after Regular Hours Language ..................................... 22
and on Weekends ............................... 12 R. Information for Members
Health Care Away From Home ........... 12 Who Are Pregnant or Have Just
Follow-Up Care After Emergency Had a Baby .................................. 23
Services or Urgent Care...................... 12 S. If You Need An Abortion .............. 23
Vision, Dental Care and Mental T. Birth Control and Other
Health .................................................. 12 Family Planning Services ............ 24
American Indian Services ................... 12 U. HIV/AIDS Testing and
Fee-for-Service Medi-Cal (“Regular Treatment For Sexually Transmitted
Medi-Cal”) ........................................... 13 Diseases ...................................... 24
V. Direct Access To A Women’s
4. Health Plan Services ......................... 13 Health Specialist .......................... 24
W. For Members Under
Covered Services ................................ 13 18 Years of Age ........................... 24
Services Not Covered by the Plan ...... 13 X. If Your Child Has Severe
Medical Problems or Doesn’t Seem
5. Problems, Complaints, and to Be Developing the Right Way .. 26
Grievances ......................................... 14 Y. Waiver Programs ......................... 27
3. Frequently Asked Questions .......... 28
Solving Problems ................................ 14
The Complaint/Grievance Process ..... 14 A. What Is the Difference Between
State Oversight of the Grievance Medi-Cal and SFHP? ................... 28
Process ............................................... 14 B. Why Can’t I See Any Provider I
The Member Advisory Committee ...... 15 Want?........................................... 29
B. Summary of Benefits .......................... 16 C. What Does It Mean to Get
“Authorization”?............................ 29
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
D. What Should I Do If I Didn’t A. Acupuncture Services .................. 47
Get a Member ID Card, I Lost B. Adult Day Health Care ................. 47
It, or I Don’t Want to See the C. Case Management Services........ 47
Provider Listed on the Card? ........ 29 D. CCS Services............................... 47
E. What Happens If My Primary Care E. Chiropractic Services ................... 48
Provider Leaves SFHP? ............... 30 F. Cosmetic Services ....................... 48
F. How Does SFHP Get Paid and G. Dental Care .................................. 48
How Does SFHP Pay Its Providers H. Exams and Services .................... 48
and Hospitals? .............................. 30 I. Experimental or Investigational
G. What Happens If SFHP Doesn’t Pay Care ............................................. 48
For My Medical Care? ................. 31 J. Hair Loss or Growth Treatment ... 48
H. What Should I Do If I Get a Bill For K. Infertility Services and Conception
Medical Care? .............................. 31 by Artificial Means ........................ 48
I. Is There Any Way For Me to Tell L. Lab Services ................................ 48
People What I Want Done If I Get M. Local Education Agency
So Sick or I Can’t Make Decisions Assessment Services .................. 49
For Myself?* (*Adapted from N. Personal Care Services ............... 49
Department of Health Care O. Prayer Healing ............................. 49
Services) ....................................... 31 P. Reversal of Sterilization ............... 49
4. Care That SFHP Covers .................... 34 Q. Routine Foot Care Services
(Podiatry) ..................................... 49
A. Hospital Inpatient Care ................. 34
R. Services Not Available in
B. Labor and Delivery ....................... 35
San Francisco .............................. 49
C. Outpatient Care ............................ 35
S. Sexual and Erectile Dysfunction
D. Chemical Dependency Services... 36
drugs ............................................ 49
E. Dialysis Care................................. 36
T. Sexual Reassignment Surgery .... 49
F. Durable Medical Equipment
U. Targeted Case Management
(DME) ........................................... 36
Services ....................................... 49
G. Family Planning Services ............. 36
V. Travel and Lodging Costs ............ 49
H. Food/Vitamins/Diet Items ............. 37
W. Tuberculosis................................. 50
I. Health Education .......................... 37
X. Waiver Programs ......................... 50
J. Hearing Services .......................... 37
Y. Limitations .................................... 50
K. Home Health Care ........................ 38
Z. Reductions ................................... 50
L. Hospice Care ................................ 38
7. Termination of Coverage ................. 51
M. Imaging and Lab Services ............ 39
N. Medical Transportation ................. 39 A. If You Get Cut-Off From
O. Mental Health Services................. 40 Medi-Cal....................................... 51
P. Ostomy and Urological Supplies .. 40 B. Start of Coverage ......................... 51
Q. Pharmacy Services ....................... 41 C. When Your Coverage Ends ......... 51
R. Administered Drugs ...................... 41 D. Coverage for Your New Baby ...... 52
S. Diabetes Urine-Testing Supplies .. 41 E. Adopted Children ......................... 52
T. Insulin-Administration Devices ..... 41 F. Foster Children ............................ 52
U. Birth Control Drugs and Devices .. 41 G. How to Leave SFHP .................... 52
V. Outpatient Drugs .......................... 41 H. Disenrollment ............................... 52
W. Our Drug Formulary ...................... 42 I. Losing Your Medi-Cal Eligibility ... 53
X. Prosthetic and Orthotic Devices ... 42 J. Help With Legal Matters .............. 53
Y. Internally Implanted Devices ........ 43 8. Help In Solving Problems ................ 53
Z. External Devices ........................... 43
A. What Do I Do If I Have a Complaint?
AA. Reconstructive Surgery ................ 43
Can I Just Call SFHP? ................ 53
BB. Mastectomy .................................. 43
B. How Long Will It Take You to Look
CC. Sensitive Services ........................ 43
Into and Answer My Complaint? . 54
DD. Services Related to Clinical
C. What If I Don’t Like How SFHP Has
Trials ............................................. 44
Answered My Complaint? ............ 54
EE. Skilled Nursing Facility Care......... 44
D. Are There Any Rules You Have to
FF. Therapy and Rehabilitation
Follow When You Look Into My
Services ........................................ 45
Complaint? ................................... 55
GG.Transplant Services ...................... 45
E. What If I Need You to Decide In
HH. Vision Services ............................. 46
Less Than 30 days? .................... 55
5. Care That SFHP Does Not Cover ..... 46
F. Do I Have to Help You with My
6. Medi-Cal Members That Still Have Complaint? ................................... 56
Optional Benefits ............................. 47
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
G. Do I Have to Complain Only to
SFHP? Can I Complain Anywhere
Else? ............................................. 56
H. Can I Get Someone Besides
SFHP to Look Into a Denial of
Medical Services? ........................ 56
I. What Do I Do If I Have Been Denied
a Request for Services That SFHP
Describes As Experimental or
Investigational in Nature ............... 57
9. Your Rights and Responsibilities.... 57
A. Your Rights ................................. 57
B. Your Responsibilities ................. 58
10. Other Facts About SFHP .................. 59
B. Public Policy Participation ........ 60
C. Non-Assignability ....................... 60
D. Independent Contractors ........... 60
E. Confidentiality of Medical
Information .................................. 61
F. Benefit Program Participation ... 61
G. Governing Law ............................ 61
H. Natural Disasters, Interruptions,
Limitations................................... 61
11. Organ Donation ................................. 61
12. Words You Should Know ................ 62
Neighborhoods Covered by SFHP...... 67
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
group or SFHP before you can see
A. Quick Guide a different provider (See page 29
for exceptions).
1. Getting Started Help in Other languages and for
the Hearing Impaired
If English is not your main language, or
you would be more comfortable speaking
another language, Member Services can
About Your SFHP Member help you find a provider who speaks your
Handbook language. Our Member Services
Your SFHP Member Handbook contains representatives speak many languages.
important information. It tells you: If we don’t have a representative who
speaks your language, we have interpreters
• How to choose or change your available by telephone. You have a right to
primary care provider or PCP interpreter services, including sign language
• How your PCP will help you get interpreters on a 24-hour basis at
primary, specialty, and hospital care no cost to you when you receive medical
care or use medical services. You also
• What you should do if you have have a right to ask for face-to-face or
a question or problem telephone interpreter services and to
Detailed information about your benefits not use friends or family members as
and services available to you are in the interpreters unless you request it.
Summary of Benefits and Evidence of
Coverage sections of this Handbook. SFHP has availability of linguistic
services and members can request
How Managed Care Works to receive information documents
San Francisco Health Plan (SFHP) translated into threshold languages.
is a managed care plan. It provides care to Member Services also uses the
members who live or work in its service area Telecommunications Device for the Deaf
which is the City and County of San (TDD) and the California Relay Services
Francisco. In managed care, your primary to help callers with a hearing impairment.
care provider (PCP), clinic, hospital, and To access the TDD services, please call
specialist work together to care for you. (415) 547-7830 (local), or (888) 883-7347
Your PCP provides basic health care needs. (toll free).
Your PCP is the main provider of your health Your Member ID Card
care. Your PCP is part of a medical group.
A medical group is a group of doctors who SFHP mails a member ID card to all
have business together and have a contract members. Check the information on your
with SFHP to give services to SFHP member ID card as soon as you receive
members. A medical group consists of it to make sure it is correct. Call Member
physicians who are primary care providers Services at (415) 547-7800 (local) or
(PCPs), specialists and other providers of (800) 288-5555 if:
health care services. A hospital is also • Any information is not correct
connected with the medical group. Your
PCP and medical group direct the care for • You move, or any information changes
all of your medical needs. This includes • The card is lost or stolen
approvals (if required) to see specialists, or Keep the member ID card with you so
to receive medical services such as lab you have it when you are getting care for
tests, X-rays, and/or hospital care. yourself or your child. The member ID card,
When you choose a PCP, you are and your Medi-Cal ID card must be shown at
also selecting the specialists and other the provider’s office, clinic, hospital,
health professionals who work for that pharmacy, or wherever else services are
medical group. Sometimes there may provided.
not be a physician available in the medical
group who can treat you. In that case, you
will be referred to a provider from another
medical group. Your PCP will get the
permission for you to see this provider,
because you must always have a prior
approval from either your PCP, medical
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
The picture below shows you what the on what to do. Your PCP is available 24
member ID card looks like. hours a day, 7 days a week. If you need
care, your PCP will provide treatment,
refer you to a specialist or arrange for
hospitalization. Your PCP’s phone
number is on your member ID card.
What Kind of Provider Can Be
a PCP?
Your PCP can be in:
• Pediatrics: Health care for children
• General Practice: Health care for
the whole family
• Family Practice: Health care for
the whole family
• Internal Medicine: Health care for adults
• Obstetrics/Gynecology (OB/GYN):
Health care for women and
pregnant women
• Nurse practitioners, certified nurse
midwives, and physician assistants are
also available as primary care providers,
as long as they practice with an
SFHP physician.
PLEASE READ THE FOLLOWING How Do I Choose a Nurse
INFORMATION SO YOU WILL KNOW Practitioner or Physician’s
FROM WHOM OR WHAT GROUP OF
PROVIDERS HEALTH CARE MAY BE Assistant As My PCP?
OBTAINED You can request to receive your primary
care services from a nurse practitioner,
2. Choosing Your certified nurse midwife or a physician
assistant. These types of providers are
Primary Care called mid-level providers. You can select
a mid-level provider from the SFHP Provider
Provider (PCP) Directory. Mid-level providers also work
closely with a primary care physician.
If you are pregnant or you are planning to
become pregnant, you also have the right
What is a Primary Care Provider to select an out-of-plan Certified Nurse
(PCP)? Midwife. You will also be assigned to the
A primary care provider (PCP) is your primary care physician who supervises the
personal doctor or health professional. nurse practitioner, certified nurse midwife
Your PCP works with you to keep you or physician assistant. When you get your ID
healthy. A PCP will provide all your card, the supervising physician’s name and
basic health care, including: the mid level provider’s name you are
assigned to will appear on your ID card.
• Regular check-ups and preventive
services such as immunizations (shots), You can contact your PCP or medical group
hearing tests, and laboratory tests to find out what healthcare practitioners are
available for you to see.
• Care when you are sick or injured
• Help with ongoing health problems Where Do PCPs Work?
like asthma, allergies, or diabetes Your PCP may work in a:
Also, the PCP will send (refer) you to a
• Private Office
specialist and arrange for hospital care
if it is needed. • Health Center
If you think you need medical care, • Hospital Clinic
call your PCP first, unless it is an • Federally Qualified Health Center
emergency. The PCP will advise you
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Native American Health Service Here are some things you may want
Facility (Indian Clinic) to think about when choosing a PCP:
Your PCP’s Medical Group • Is the PCP close to home, school,
Every PCP and clinic in SFHP is part or work?
of a medical group. A medical group • Is it easy to get to the PCP by MUNI,
is made up of many providers and other bus, or BART?
health professionals who work together. • Does the office staff speak
Each medical group works with an your language?
assigned hospital.
• Does the PCP work with a hospital
When you choose a PCP, you are also that you like?
assigned to the specialists in the PCP’s
• Does the PCP see children of all ages?
medical group and the hospital they work
with. Your PCP will refer you to those Call us at (415) 547-7800 (local) or
specialists for most specialty care. (800) 288-5555 and tell us which PCP you
would like to choose. If you have more than
If you have to go to the hospital, you will one child, you may choose a different PCP
go to the hospital that works with the PCP’s for each child. We will send you a member
medical group. Your PCP will obtain the ID card that includes the PCP’s name and
necessary permissions for care that you phone number. SFHP wants you to have
need. If you go to a specialist without a PCP who is right for you. If you did not
approval from your PCP, the cost of that choose your own primary care provider
visit may not be covered by SFHP. Refer (PCP) when you became a member or
to page 19 of the Evidence of Coverage within 30 days of joining SFHP, SFHP will
section for a complete description of the assign one to you.
approval process. If you prefer a particular
specialist or hospital, make sure your PCP Using the Provider Directory
and their medical group works with those The provider directory is available in
providers. If you see a specialist or PCP English, Spanish, Chinese, Vietnamese,
who is not with your medical group, without and Russian.
permission or in a situation that is not an
emergency, SFHP will not pay for it. Always It contains the address and telephone
go to your PCP and stay with the providers number of each service location (e.g.,
in that medical group, unless SFHP or the locations of hospitals, Primary Care
medical group approves services elsewhere. Physicians (PCP), Specialists,
Optometrists, Pharmacies, Skilled Nursing
Remember, an approval is never needed Facilities, Urgent Care Facilities, FQHCs
to see your PCP, emergency services, and Indian Health Centers). In the case of
preventive services, OB/GYN care, family a medical group/foundation or independent
planning services or other sensitive practice association (IPA), the medical
services. You do need to stay within your group/foundation or IPA name, address
medical group if you need an abortion. and telephone number appears for each
Refer to page 29, “What Does It Mean Physician provider.
to ‘Get an Authorization’?” for a complete
description of when you need to get It also has the hours and days when
a permission for services and when each of these service locations is open,
you do not. the services and benefits available, the
telephone number to call after normal
Choosing Your PCP business hours, and identifies providers
Every member has a primary care provider that are not accepting new patients.
(PCP). You may have already chosen a
PCP for yourself when you joined SFHP. Changing Your PCP
If you did not choose your own primary care If you are not happy with your PCP
provider (PCP) when you became a member for any reason, call Member Services
or within 30 days of joining SFHP, SFHP will at (415) 547-7800 (local) or
assign one to you. (800) 288-5555 at any time to request
a change. A new member ID card will be
You can always call SFHP and ask to issued and mailed to you. The new card
change to a different PCP if you do not will have the name and phone number
like the PCP we assigned you. of your new PCP.
You can also look in the Provider Directory IMPORTANT NOTE: If you need to see
to choose another PCP. a PCP before you get a new card with the
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
name of the new PCP on it, call Member 6. Except in the case of an emergency,
Services at (415) 547-7800 (local) or always call the PCP first when you get
(800) 288-5555. A representative will sick or hurt. Your PCP or a substitute
tell you which PCP to see. provider, is available 24 hours a day, 7
days a week. Your PCP will make sure
Why Can a Provider Request a you get the health care you need, either
Change in Member’s PCP? by providing treatment or sending you to
• Irreconcilable breakdown in physician- a specialist.
patient relationship Specialty Care
• Physical assault and violent behavior by The PCP will arrange most types
member including physical threatening of specialty care that you may need.
and verbal and physical abuse After talking with you, the PCP will send
• Member fraud (refer) you to a specialist. The specialist
is a member of your medical group. If your
• Non-compliance with PCP’s care PCP determines that a specialist is not
management plan available within the medical group, your
• Member habitually uses providers not PCP will send you to another specialist.
affiliated with SFHP for non-emergency If you go to another provider without a
services without required approvals or referral from the PCP, these services
communication with the PCP. may not be paid for by SFHP.
3. Getting Care Unless it is an emergency, always call your
PCP first if you are able to. For specialty
Under Your care referrals in which you need medical
tests or treatment that your doctor cannot
New Health Plan perform, you should be able to schedule
an appointment within 14 business days.
Urgent specialty care referrals in situations
where you need important medical tests or
Getting Care when your health is at risk, you should be
As a member of San Francisco Health Plan, able to schedule an appointment within 2
you will find getting health care is simple. business days. If it takes longer to see a
Specialist, please call SFHP Member
Just follow these steps:
Services at (800) 288-5555/TDD
1. Schedule check-ups and (888) 883-7347 for help.
routine care.
2. Do not wait until you are sick to see
Family Planning
your PCP. Schedule an appointment for Family planning services are provided for
a health assessment (check-up) within all members, men and women without a
120 days of enrollment. For children referral from your PCP. These services
under the age of two, please make an can help you decide if and when you want to
appointment with your child’s PCP have children. Family planning includes
within 60 days of enrollment with SFHP birth control and testing for pregnancy,
or as soon as possible. Your PCP will sexually transmitted diseases and HIV
advise you about the best time for testing and counseling. You can get family
routine appointments and shots. planning services from your PCP or any
other provider within the SFHP network who
3. Call and make an appointment,
offers family planning services. You can
4. Call your PCP on your member ID card also obtain family planning services from
to schedule an appointment. Show your out-of-network family planning providers.
member ID card, and your Medi-Cal ID
card at the PCP’s office or clinic. Please Female members can get direct access
give at least 24 hours notice if you need and make an appointment for women’s
to cancel or change the appointment. If health care directly with an OB/GYN or a
English is not your main language or family practice provider within their medical
you would be more comfortable group, without a referral from their PCP for
speaking another language, please let women’s routine and preventive health care
your PCP’s office know so that they can services (such as pap smears, breast
make plans for an interpreter to be on checks, mammograms, etc.). If you would
hand. like help with family planning services, you
can call your PCP. The phone number is
5. Contact your PCP when you are sick
listed on your member ID card. You can also
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
call San Francisco Health Plan or any family Medical Director makes the final decision to
planning provider within or outside of deny or change the request or ask the
SFHP’s network who you want to see. doctor for more information.
Second Opinions If the request form is complete, standard
requests are often done within 24 hours or
If you would like to talk to another provider
one business day and urgent requests are
about a health problem, you may ask your
often done within four business hours.
PCP for a second opinion. SFHP will pay
Requests that cannot be read or do not
for an opinion from another specialist when
have complete information may take longer.
the PCP refers you. The specialist usually
is within your medical group or another If the prior authorization is approved, a
medical group that has a contract message is sent by fax to the person who
with SFHP. sent the prior authorization form and the
claim will be covered by SFHP. If the prior
Pharmacy Services authorization is denied, changed, or more
When you need medication, your PCP or information is needed, SFHP will send a
referred specialist will prescribe it. To get letter to the member and prescribing
the medication, take the prescription to a physician and/or PCP. This letter includes
pharmacy listed in the Pharmacies section in the reason for SFHP’s decision.
the San Francisco Health Plan Medi-Cal
Provider Directoryand show your member ID Facilities
card to the pharmacist. SFHP has a drug For the name and locations of all
formulary. The drug formulary is the list contracted SFHP facilities, please call
of drugs that SFHP will pay for. You can Member Services at (415) 547-7800
request information whether a specific (local) or (800) 288-5555 or please
drug is on the formulary by calling refer to the Provider Directory.
Member Services at (415) 547-7800
(local) or (800) 288-5555. Even if a drug Hospital Care
is listed on the SFHP drug formulary, If you are sick or hurt, call your PCP.
it does not make certain that it will Your PCP will either see you, send you
be ordered by your doctor for a to a specialist, or send you to the hospital.
particular condition. If you have to go to the hospital, it will be
If your medication is not part of the SFHP the hospital where your PCP works. If you
formulary, your provider must submit a have special health care needs, your PCP
special form to SFHP. SFHP will review or specialist may need to send you to
the request and decide if you can use a another hospital that provides the services
non-formulary drug. needed. (If there is a particular hospital that
you prefer, be sure and check the hospital
PRIOR AUTHORIZATION PROCESS: listed when choosing your PCP).
The SFHP Prior Authorization (PA) form Remember, you do not need to call
may be filled out by the prescribing doctor, your PCP first if it is an emergency.
doctor’s assistant or the pharmacist. A Prior
Emergency Medical Care
Authorization form can be found on the
SFHP website at http://www.sfhp.org. An emergency is when you:
A complete request form may be sent • Have a condition where it
to SFHP three ways. looks like your life is in danger
Fax standard requests to Informed Rx at • Are in extreme or intense pain
(866) 511-2202; • Have serious difficulty breathing
fax urgent requests to(877) 636-9001. • May have a broken bone
E-mail requests to Please refer to page 63 for a full definition
IncomingPAsUrg@sxc.com. of Emergency Medical Condition.
Fill out request form online at: When you have a medical emergency:
www.nmhcrx.com
1. Call 9-1-1 or go to the closest
The pharmacist and/or the SFHP Medical emergency room for help
Director review prior authorizations and 2. Show your member ID
decide to approve, deny or change the card to the hospital staff
request or ask the doctor for more
3. Ask the hospital staff to
information. The SFHP pharmacist or
call your PCP
6534 E 0110 11
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
If you are not sure if it is an emergency, services or urgent care to find out
call your PCP to find out if you need to what you should do.
go to the emergency room. If you go to
the hospital emergency room for care when Vision, Dental Care and
you truly believed that it was an emergency, Mental Health
SFHP will pay for the visit, even if it later Children under the age of twenty one (21)
turned out not to be an emergency. enrolled in the SFHP Medi-Cal Program,
should already be enrolled in mental health
Urgent Care after Regular Hours
and dental plans.
and on Weekends
SFHP will cover select hospital services
Some medical problems may require
required for special dental care. All other
urgent care but are not emergencies. Urgent
dental and mental health services for
medical problems are problems that usually
children under the age of twenty one (21)
need attention within 24 to 48 hours. If you
are covered under separate Medi-Cal
think you have an urgent medical problem,
sponsored Dental and Mental Health plans
call your PCP’s office. Your PCP, or a
and providers.
substitute provider, is always available 24
hours a day, 7 days a week, to help if there • For more information on your dental
is an urgent medical problem. They will tell plan, call Denti-Cal at (800) 322-6384.
you what to do.
• For more information on your mental
You have a right to interpreter services health benefits, call San Francisco
at no cost to you on a 24-hour basis Community Behavioral Health Services
when you receive medical care or use (SFCBHS) at (415) 255-3737 or
medical services. For more information, (888) 246-3333 (toll free).
please call SFHP Member Services • As of July 1, 2009, most adults age
at (415) 547-7800 (local) or twenty one (21) and older on Medi-Cal
(800) 288-5555. have limited access to dental and
mental health services. Please call the
Health Care Away From Home
numbers above for more information
If you need emergency care while not in about the services available to you.
San Francisco County, SFHP will pay for it.
For vision services, SFHP members who are
1. Call 9-1-1 or go to the nearest children under the age of twenty one (21) or
emergency room adults age twenty one (21) and older with
2. Show them your member ID card diabetes are automatically enrolled in Vision
Service Plan. Generally, services are not
3. Have your PCP call SFHP as soon
covered for adults age twenty one (21) and
as possible.
older. SFHP does cover medically
The number for SFHP is also listed on your necessary eye examinations, from an
member ID card. If you need urgent care ophthalmologist, for all members.For more
while you are away from home, call your information about the vision plan, please
PCP and he or she will tell you what to do. call SFHP Member Services at
(415) 547-7800 (local) or (800) 288-5555.
Follow-Up Care After Emergency
Services or Urgent Care Vision, Dental Care, and Mental Health
coverage are limited benefits for certain
Follow-up care received after emergency
members only. Please see page 46 for a
services or urgent care must be arranged
description of the limitations and exceptions.
by your primary care provider. If you need
follow-up care after you have received American Indian Services
emergency services or urgent care, you
If you are an American Indian, you have the
should call your PCP so that he or she can
right to receive your services from a
arrange the care that you need. Your PCP
Federally Qualified Health Center (FQHC) or
may see you or may refer you to a specialist
an Indian Health Service facility. If you
who can provide you with the care that you
would like to receive services from an
need. If you receive follow-up care after
FQHC, SFHP can tell you which of the
receiving emergency services or urgent care
clinics in our network are FQHC’s. To get
from any provider who is not a participating
information on FQHC’s or an Indian Health
provider and SFHP has not authorized the
Service facility, call SFHP Member Services
services, you may be responsible for the
at (415) 547-7800 (local) or (800) 288-5555.
cost of those services. Contact your primary
You have the right to disenroll from SFHP at
care provider after receiving emergency
any time, without cause. You also have the
6534 E 0110 12
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
right to not participate in a managed care San Francisco Health Plan is responsible to
plan (See page 52 for information on how pay for all covered services including
to disenroll from SFHP). emergency services. You are not
responsible to pay a provider for any amount
Fee-for-Service Medi-Cal owed by the health plan for any covered
(“Regular Medi-Cal”) service.
When you are a member of a managed care If San Francisco Health Plan does not pay a
plan, the State pays the Plan on a monthly non-participating provider for covered
basis even if you do not receive services. services, you do not have to pay the non-
You must see the providers who participate participating provider for the cost of the
with the Plan except in cases of covered services. Covered services are
emergencies or when getting family those services that are provided according
planning or sensitive services. to this Evidence of Coverage booklet. The
non-participating provider must bill San
With Fee-for-Service Medi-Cal, (sometimes
Francisco Health Plan, not you, for any
called regular Medi-Cal) you can see any
covered service. But remember, services
provider that will accept Medi-Cal patients.
from a non-participating provider are not
The State pays the providers for the
covered services unless they fall within the
services they provide to you. If you think
situations allowed by this Evidence of
that you should be receiving care through
Coverage booklet.
regular MediCal, call Health Care Options
at (800) 430-4263. If you receive a bill for a covered service
from any provider, whether participating
Some services are not covered by or non-participating, contact the San
managed care Medi-Cal and are only Francisco Health Plan member services
provided by regular Medi-Cal. These department at (415) 547-7800 (local) or
services include some mental health (800) 288-5555.
benefits, dental services, acupuncture,
chiropractic services, and organ transplants
(except kidney and corneal Services Not Covered by the Plan
transplants).There are other services that You may have to pay for services you
are only covered by regular Medi-Cal. You receive that are NOT covered services, such
can still continue to be a member of SFHP as:
while you receive some of these managed
care non-covered services from regular • Non-emergency services received in the
Medi-Cal. You can get more information emergency room;
about these services by calling SFHP
• Non-emergency or non-urgent services
Member Services at (415) 547-7800
received outside of San Francisco
(local) or (800) 288-5555.
Health Plan’s service area if you did not
get authorization from San Francisco
4. Health Plan Services Health Plan before receiving such
services
• Specialty services you receive if you did
Covered Services not get a required referral or
SFHP will pay only for services that are authorization from San Francisco Health
emergent, urgent or that are medically Plan before receiving such services (see
necessary and provided by the PCP, or page 21, section H. How to See a
specialist to whom the PCP referred you, Specialist)
as required and authorized according to • Services from a non-participating
SFHP’s procedures. Please see the provider, unless the services are for
detailed description of how to use your situations allowed in this Evidence of
covered services in the Evidence of Coverage booklet (for example,
Coverage section on page 19, emergency services, urgent services
“How To Get Care,” in the Handbook. outside of San Francisco Health Plan’s
service area, or specialty services
approved by San Francisco Health Plan
(see page 7, How Managed Care
Works)
• Services you received that are greater
than the limits described in this
6534 E 0110 13
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Evidence of Coverage booklet unless translation services, or want a referral to
the services were authorized by San community advocates, please call Member
Francisco Health Plan Services at (415) 547-7800 (local) or (800)
288-5555 (toll free)-. SFHP has availability
We may be able to help you get services
of linguistic services and members have the
that are not covered. Even though some
right to receive information documents
services are not covered by SFHP, it may be
translated into threshold languages.
covered through regular Fee-For-Service
Medi-Cal. We may be able to help you get Any expression of dissatisfaction is
them through regular Medi-Cal. Please refer considered a grievance. Filing a complaint
to page 46 in the Evidence of Coverage or grievance is your right. SFHP will not
section of this Handbook for services that discriminate against you. You will not be
are not covered. For more information, disenrolled or lose eligibility for the Medi-Cal
please contact Member Services Program coverage because you filed a
at (415) 547-7800 (local) or (800) 288-5555. complaint or a grievance.
The full range of benefits is available You do not have to participate in the
through SFHP’s provider network. SFHP’s grievance process before going
None of SFHP’s contracted provider to the Department of Managed Health Care
raise an objection to performing or (DMHC) or to the Department of Health
otherwise supporting any covered service. Care Services (DHCS) if you have an
SFHP will respond with timely referrals urgent grievance. Urgent grievances are
and coordination in the event that a those cases involving, but not limited to,
benefit/covered service is not available severe pain, potential loss of life, limb or
within from a SFHP provider because major bodily function. When you call us with
of religious, ethical or moral objections an urgent grievance, we will inform you of
to the covered service. your right to go to the DMHC or DHCS.
Please see pages 53 to 57 of the Evidence
5. Problems, of Coverage section in the Handbook for
Complaints, and more information about the grievance
process, or call Member Services at (415)
Grievances 547-7800 (local) or (800) 288-5555.
State Oversight of the
Grievance Process
Solving Problems The California Department of Managed
SFHP wants you to have the best care and Health Care (DMHC) is responsible for
service possible. We want to hear from you regulating SFHP and other health care
when you are happy with your health care service plans. The DMHC has a toll-free
services. We also want to help you work telephone number at (888) 466-2219
out any problems you may have. to hear complaints about health plans.
If there is a problem, try to talk about The hearing and speech impaired may use
it when it first happens. Talking with your the California Relay Service’s toll-free
PCP or other providers may be the best number 1(877) 688-9891 (TDD) to contact
way to get an issue settled quickly. DMHC. The DMHC’s Web site
(www.hmohelp.ca.gov) has complaint
If the problem is not resolved, call us. forms and instructions online.
Member Services will work with you to fix
the problem. If we still cannot resolve the If you have a grievance against SFHP,
problem, you may file a formal complaint you should contact SFHP and use SFHP’s
or “grievance.” grievance process. You may call DMHC if
you need help with a complaint involving an
The Complaint/Grievance Process emergency grievance or with a grievance
If you have a complaint about any services that has not been resolved by SFHP
that you receive from SFHP or its providers, within 30 days or to your satisfaction.
you may file a grievance with SFHP. This You also have the right to contact the
complaint may be made verbally, by Department of Health Care Services for a
telephone, in writing, or through SFHP’s complaint about your Medi-Cal benefits. You
website at www.sfhp.org. Grievance forms may contact the State Ombudsman’s office
are available online, at each PCP’s office to complain or you can call the State to
or from Member Services. If you need request a State Fair Hearing.
assistance with filling out the form, require
6534 E 0110 14
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
You may call the State Ombudsman for help
with a grievance. The Ombudsman Office is
reached toll-free at (888) 452-8609. The
TDD number is (800) 430-7077. Its office
hours are Monday-Friday, 8:00am to
5:00pm, closed on State holidays.
Information regarding the State Fair
Hearing process is available by calling
(800) 952-5253, (800) 430-7077 (TDD)
or by writing:
California Department of Social Services
State Hearing Division
P.O. Box 944243, MS 19-37
Sacramento, CA 94244-2430
The Member Advisory Committee
San Francisco Health Plan’s Member
Advisory Committee (MAC) is the place
for SFHP members to share concerns
and give advice to the SFHP Governing
Board about how SFHP can better serve
its members. MAC is made up of SFHP
members and health care advocates.
It works to improve the quality of care
and to discuss the concerns of SFHP
members. MAC promotes quality
health care and invites you to join the
committee. The Committee meets the first
Friday of every month at the SFHP office.
Call the Member Advisory Committee
at (415) 547-7818 x 4235, to attend
a meeting or to ask about joining.
6534 E 0110 15
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
B. Summary of Benefits
A Chart To Help You Compare Coverage Benefits
This CHART BELOW is to help you compare coverage benefits and is a summary only.
You should look at the Evidence of Coverage (EOC) for a detailed description of coverage
benefits and limitations. Limitations are the most that SFHP will cover in terms of cost and
services. For all covered services, there are no co-payments.
Benefit Covered Services Member Pays
Deductibles No deductibles
Lifetime Maximum Unlimited
Professional Services Physician visits including specialty care, No co-payment
inpatient and outpatient medical and surgical
services
Outpatient Services In a physician’s office, surgery center, or other No co-payment
designated facility
Chemotherapy, dialysis, and radiation No co-payment
Hospitalization No co-payment
Inpatient Services Medically necessary facility charges room and
board, general nursing care, ancillary services
including operating room, intensive care unit,
prescribed drugs, laboratory, and radiology
during inpatient stay
Outpatient Services Medically necessary facility charges, general No co-payment
nursing care, ancillary services including
operating room, prescribed drugs, laboratory,
chemotherapy, and radiology
Emergency Health Coverage 24-hour care for emergency services including No co-payment
psychiatric screening, examination and
treatment, injury or condition requiring
immediate diagnosis in and out of the Plan
Ambulance Services Ambulance transportation when medically No co-payment
necessary
Prescription Drug Coverage Maximum 30 day supply for most drugs; No co-payment
up to 100 day supply of maintenance drugs;
tobacco cessation drugs for one cycle per
benefit year with completion of an SFHP
approved tobacco cessation program
Inpatient drugs and drugs administered in
a provider’s office, as well as FDA approved
contraceptive drugs and devices
Durable Medical Equipment Crutches, wheelchairs, walkers and home No co-payment
oxygen equipment
Home Health Services Medically necessary skilled care (not No co-payment
custodial); nursing care, home visits, physical,
occupational and speech therapy
6534 E 0110 16
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Benefit Covered Services Member Pays
OTHER Therapeutic radiological services, ECG, No co-payment
EEG, mammography, other diagnostic
Diagnostic X-ray and laboratory and radiology tests, laboratory
Laboratory Services tests for the management of diabetes
Preventive Care Immunizations, periodic health exams, well- No co-payment
child visits, STD tests, cytology exams,
prenatal care
Perinatal/Maternity Care Prenatal and postnatal care, inpatient, No co-payment
newborn nursery care while the mother is
hospitalized and for the first month and the
following month of life. Genetic testing is
covered for PKU only.
Family Planning Counseling surgical procedures for No co-payment
sterilization, contraceptives, elective
abortion
Skilled Nursing Facilities Medically necessary skilled care; room and No co-payment
board; X-ray, laboratory and other ancillary
services; medical social services; drugs,
medications and supplies. Skilled nursing
services are covered from the day of
admission and up to one month after the
month of admission.
Kidney Transplants Medically necessary kidney transplant; No co-payment
medical and hospital expenses of a donor
or prospective donor; testing expenses
and charges associated with procurement
of donor organ
Health Education Health education materials and classes No co-payment
CCS Benefits provided through California No co-payment
Children’s Services for benefits
related to CCS eligible conditions
Hospice Medically necessary skilled care; No co-payment
counseling, drugs and supplies; short-term
inpatient care for pain control and system
management; bereavement services,
physical, speech and occupational
therapies; medical social services
short-term inpatient and respite care
Hearing Aids/Services Audiological evaluations, hearing aids, No co-payment
supplies, visits for fitting, counseling,
adjustments, andrepairs.
6534 E 0110 17
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Benefit Covered Services Member Pays
Hearing Aids/Services Audiological evaluations, hearing aids, No co-payment
supplies, visits for fitting, counseling,
adjustments, andrepairs.
Eye Exams/Supplies For children under the age of twenty one No co-payment
(21) and adults age twenty one (21) and
Covered through your older with diabetes only. Vision coverage is
Vision Service Plan a limited benefit for certain members only.
Services are generally not covered for non-
diabetic adults age twenty one (21) and
older. See page 47, “Medi-Cal Members
That Still Have Optional Benefits” for a
description of limitations and exceptions.
For more information see “HH. Vision
Services” on page 46.
Refractions test to determine the need for
corrective lenses; dilated retinal eye exams;
cataract spectacles and lenses.
Eyeglass frames and lenses for children
under the age of twenty one (21) only.
Services are generally not covered for adults
age twenty one (21) and older. See page
46“Medi-Cal Members That Still Have
Optional Benefits” for exceptions.
Medically necessary eye examinations, from
an Ophthalmologist, for all members.
6534 E 0110 18
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
midwives, and physician assistants must
be supervised by an SFHP PCP.
C. Evidence of Your PCP works with you to
keep you healthy. A primary care
Coverage provider will provide all your basic
healthcare, including:
• Check-ups and services to keep
1. About San Francisco you healthy, like shots for children
• Care when you are sick or hurt
Health Plan (SFHP)
• Help with ongoing health problems
like asthma, allergies, or diabetes
San Francisco Health Plan (SFHP) • Sending you to a Specialist or
is a licensed health plan for people living the hospital if you need it
in San Francisco. Please refer to page 67 As an SFHP member, you have to pick
for boundaries of San Francisco. The health a primary care provider (PCP). Your
plan does not provide the medical care, but PCP will manage your care, sending
arranges for health care services to be you to specialists or a hospital when
provided to its members. All health care needed.
services you receive are offered by
1. Call your PCP to schedule a check
independent providers, clinics, hospitals,
up for a new patient as soon as
and other health professionals who do
possible. It’s important for you and
not work for SFHP. These providers and
your PCP to get to know each other
hospitals have agreed to provide services
so your PCP can keep you healthy.
to SFHP members.
2. Unless it is an emergency, or
A. Check Your SFHP you require out-of-area urgent
services, you must only use the
Member ID Card hospital, clinic, or specialist that is in
SFHP will send you a member ID your medical group that your PCP
card. It is important to check the card sends you to.
to make sure all the information is right. 3. Always show your SFHP member ID
If anything is wrong, or if you move, or card, and your Medi-Cal ID card
if the card is lost or stolen, call us right when you go to see any provider, go
away. Show your ID card, and Medi- to the hospital, or get your
Cal ID card anywhere you get medical prescription filled.
care. Call Member Services at (415) 4. Your PCP may need to get
547-7800 (local) or (800) 288-5555 if permission, from SFHP or from the
you have any questions about your medical group you belong to, for
health coverage. some services he or she
recommends for you. If SFHP or the
2. How to Get Care medical group decides not to
authorize a service, and you are
unhappy with the decision, you can
A. About Your Primary file a grievance.
Care Provider 5. You cannot go to any provider
or hospital that you want. Unless
A primary care provider (PCP) is your
you need emergency care, family
personal doctor or health professional.
planning, or sensitive services, you
A PCP can be a physician, an OB/GYN
must speak with your primary care
who provides primary care services,
provider or OB/GYN provider first. If
a nurse practitioner, a certified nurse
you receive services that are not an
midwife, or a physician’s assistant.
emergency, family planning or
Nurse practitioners, certified nurse
sensitive services without first talking
6534 E 0110 19
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
to your PCP, SFHP may not pay for You do not have to call your PCP before
those services. seeking emergency services. If you are
6. Call 9-1-1 for an emergency and not sure if it is an emergency, call your
you can call your own PCP or other PCP. Your PCP will tell you if you need
providers for family planning or to go to the emergency room. You have
sensitive services. Your PCP or a the right to obtain emergency services
substitute provider is available 24 from any hospital or other setting in
hours a day, seven days a week. cases of true emergency. If you go to
Your PCP will make sure you get the hospital emergency room for care
the health care you need. Your PCP that is NOT a true emergency, the
will treat your problem or refer you emergency room may send you to your
to a specialist. PCP’s office or clinic.
B. What to Do if Your PCP’s D. Post-Stabilization and Follow-
Office is Closed up Care After an Emergency
If you feel sick or have some other
urgent medical problem, call your PCP’s Once your emergency medical condition
office even when your PCP’s office is is stabilized, your treating health care
closed. Your PCP or a provider-on-call provider may believe that you require
will always be available to tell you how additional medically necessary services
to handle the problem or if you should prior to your being safely discharged. If
go to an urgent care center or a hospital the hospital is not part of San Francisco
emergency room. Health Plan’s contracted provider
network, the hospital will contact your
assigned medical group or San
C. What to Do If You Are Out of Francisco Health Plan to obtain timely
the Area authorization for these post-stabilization
If you are out of the area and get sick, services. If the Plan determines that
but it is not an emergency, call your you may be safely transferred to a San
PCP if possible to find out what to Francisco Health Plan contracted
do. If you are in need of urgent care, hospital, and you refuse to consent to
you are encouraged to contact your the transfer, the hospital must provide
PCP first, but it is not required. SFHP you written notice that you will be
will cover care that you get outside of financially responsible for 100% of the
San Francisco, California if you have an cost for services provided to you once
emergency or urgently needed services. your emergency condition is stable.
Urgently needed services are those Also, if the hospital is unable to
necessary to prevent serious determine your name and contact
deterioration of your health, resulting information at San Francisco Health
from an unforeseen illness, injury, or Plan in order to request prior
complication of an existing condition, authorization for services once you are
including pregnancy for which treatment stable, it may bill you for such services.
cannot be delayed until you return to
see your PCP in San Francisco. IF YOU FEEL THAT YOU WERE
IMPROPERLY BILLED FOR
What to Do in Case of Emergency
SERVICES THAT YOU RECEIVED
An emergency is a sudden medical or FROM A NON-CONTRACTED
psychiatric problem with severe signs PROVIDER, PLEASE CONTACT SAN
that need treatment right away. Not FRANCISCO HEALTH PLAN AT (415)
seeking immediate care, in the event of 547-7800 (local) OR (800) 288-5555
an emergency, would place a person’s (toll free).
life, health, or body organ or part
in serious danger. Please refer to
page 63 for a full definition of
Emergency Medical Condition.
6534 E 0110 20
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
E. Changing Your PCP or If you think you need a standing referral,
Medical Group talk to your PCP.
If you are not happy with your PCP You can make an appointment with a
or medical group for any reason, call specialist once your PCP gives you a
Member Services at (415) 547-7800 referral. You should be able to get an
(local) or (800) 288-5555, and we will appointment with the specialist within
help you pick a new one. The change thirty (30) days.
may be effective the first day of the next
month. H. Getting a Second Opinion
Keep in mind: If you change your SFHP allows you to get a second
PCP to one who belongs to a different opinion. If you want a second opinion
medical group, when you need to see a about care you are getting from your
specialist or need to go to the hospital, PCP or Specialist, you may choose any
you will have to go see the specialists provider who is specially trained to treat
and the hospital in the medical group your condition (appropriately qualified
that your new PCP works with. health professional) from the same
medical group. If there is no SFHP
provider within the medical group who
F. Going to the Correct Hospital can offer a second opinion, then you
If you have to go to the hospital, can get a second opinion by a provider
you will be sent to the hospital linked with another medical group, or if
to your medical group. If there is a needed, outside of SFHP’s list of
particular hospital that you prefer, be providers.
sure to check that your PCP is linked
to it. If she or he doesn’t work at the SFHP will pay for an opinion from
hospital you want, pick another PCP another specialist when the PCP refers
who does. Remember, you never have you.
to call your PCP or get prior approval for Requests for second opinions will
any emergency services. If you have an be approved quickly. In urgent cases,
emergency medical condition, you can a second opinion will be approved
go to any hospital that is closest to you as soon as possible, usually within
and SFHP will pay for it. 72 hours.
G. How to See a Specialist I. Why Are Initial Health
Your PCP arranges most types of Assessments (IHAs) And
specialty care for you. At your visit, your Check-Ups Important?
PCP will decide right away to send you
to specialist or not. Your PCP will send An Initial Health Assessment (IHA) lets
you to a specialist who is part of SFHP. your PCP get to know you and your
If you go to another provider without a medical history. They enable your PCP
referral from your PCP, these services to comprehensively assess your current
may not be paid for by SFHP. Always acute, chronic and preventive health
call your PCP first. If your PCP does not needs. This will help your PCP take
arrange the care you need, call SFHP better care of you when you are sick. It
for help. can also help your PCP find problems
before they get more serious.
If you need to see a specialist often
because you have a life-threatening, Do not wait until you are sick to see your
degenerative, or disabling condition PCP. Make an appointment for
that requires coordination of care an initial health assessment (check-up)
by a specialist instead of your PCP, you with your PCP within 120 days of
can get a standing referral to that signing up with SFHP. For children
specialist. To get a standing referral, under the age of two, please make an
your PCP must get permission for it. appointment with your child’s PCP
within 60 days of enrollment with SFHP
6534 E 0110 21
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
or as soon as possible. It is important N. Getting Help for Alcohol or
to build a good relationship with Drug Abuse
your PCP.
If you are struggling with drug or alcohol
Some things you can do to help are: abuse, call the San Francisco
• Schedule regular checkups for Community Behavioral Health Services’
yourself and for your children Access Team at (888) 246-3333 (toll
after your first check up free) or (888) 484-7200 (TDD). They will
help you find the right care.
• Talk openly with your PCP
• Ask your PCP questions if you O. If You Have a Disability
do not understand something
If you have a disability and need to
• Follow the advice of your PCP locate a provider’s office that you can
get to, please call SFHP’s Member
J. Getting Prescriptions Filled Services for a complete listing of
When you need medication, your PCP accessible provider offices. We try to list
or specialist will prescribe it. Take the accessible provider’s offices in our
prescription to a drugstore listed in the Provider Directory also.Look for the
SFHP Provider Directory. Be sure to symbol. If you need help finding an
show your SFHP member ID card accessible provider office, please call
to the pharmacist. SFHP’s Member Services at
(415) 547-7800 (local) or (800) 288-
K. Getting Eye Exams 5555 (toll free).
and Glasses
P. Information for Members Who
To get eye exams, glasses, and
other eye-related help, call VSP
Are Hearing Impaired
at (800) 438-4560. Member Services uses the
Telecommunications Device for the
Deaf (TDD) and the California Relay
L. Getting Dental Exams and
Services to help callers who don’t hear
Other Dental Care well. To use the TDD services to talk to
To get dental care for children under the Member Services call (415) 547-7830
age of twenty one (21), or limited (local), or (888) 883-7347 (toll free).
emergency dental care for adults, call
Denti-Cal at (800) 322-6384. Effective Q. Information for Members Who
July 1, 2009, adults age twenty one (21)
and older will have limited emergency
Speak English as a Second
dental care. Dental coverage is a Language
limited benefit for certain members only. If English is not your main language,
See page 47, “Medi-Cal Members That or you would be more comfortable
Still Have Optional Benefits” for a speaking another language, Member
description of limitations and exceptions. Services can help. Our Member
Services representatives speak
M. Getting Help for Mental or many languages. If we don’t have
Emotional Problems a representative who speaks your
language, we have interpreters available
If you are having emotional or mental by telephone. Call Member Services at
problems, call the San Francisco (415) 547-7800 (local) or (800) 288-
Community Behavioral Health Services’ 5555.
Access Team at (888) 246-3333 (toll
free) or (888) 484-7200 (TDD). They will Member Services can also help
help you find the right care. SFHP you find a provider who speaks
PCP’s can also provide outpatient your language. You have a right
mental health services within their scope to interpreter services, including sign
of practice. language interpreters at no cost
6534 E 0110 22
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
to you on a 24-hour basis when you As soon as your baby is born, you
receive medical care or use medical can enroll your baby in SFHP. If you
services. You also have a right to do not enroll your baby in SFHP, your
ask for face-to-face or telephone baby will not be eligible for any benefits
interpreter services and to not use from SFHP after the end of the month
friends or family members as following the baby’s birth. For example,
interpreters unless you request it. if your baby is born on January 15, your
You can use the Provider Directory baby will be covered for January and
to find a provider who speaks your February, but will not be covered in
language. SFHP has availability March unless you apply for Medi-Cal for
of linguistic services and members the baby before March.
have the right to receive information
The Women, Infants and Children (WIC)
documents translated into
Program is a nutrition/food program that
threshold languages.
helps young children and women to eat
Member Services also uses the well and stay healthy. Children under
Telecommunications Device for five years of age, pregnant women,
the Deaf (TDD) and the California women who are breastfeeding or who
Relay Services to help callers with have just had a baby should call WIC to
a hearing impairment. To access get free food vouchers, nutrition
the TDD services, please call education, and breastfeeding support.
(415) 547-7830 or (888) 883-7347 Ask your PCP to help you apply or call
(toll free). to make an appointment at (888) WIC-
WORKS or (888) 942-9675.
R. Information for Members Who
Are Pregnant or Have Just Had S. If You Need An Abortion
a Baby SFHP covers abortions. You do
not need to see your PCP first
If you are pregnant, go see your
or get permission for an abortion. You
OB/GYN right away. It is important
may obtain outpatient abortion services
for your baby and you to see a
from an SFHP network provider or from
provider as early as possible while
a non-network provider. Prior
you are pregnant. If you do not have an
authorization for outpatient abortions is
OB/GYN, you can call your PCP for the
not required. Inpatient hospitalization for
name of a good OB/GYN. Or you can
abortions may be subject to prior
call us at SFHP and we will help you
authorization procedures as per our
find an OB/GYN. You do not need to get
permission to see an OB/GYN, but you current policies and procedure specific
to each medical group and hospital
do need to see one who is part of your
contract. You do not need the
medical group.
permission of your parents/guardian to
SFHP will cover all the services get an abortion.
you need before you give birth and for
If you need help finding someone
the birth. It is very important that when
you go to the hospital to have the baby, to perform the abortion, you can call
that you go to the hospital that is part Member Services at (415) 547-7800
of your medical group. (local) or (800) 288-5555. You can
also call the Department of Health Care
If you have a baby while you are a Services (DHCS). DHCS can offer
member of SFHP, your baby will be advice and give you a list of nearby
covered by SFHP under your name only family planning clinics. The DHCS
during the month of birth and the number is (800) 942-1054.
following month. Be sure to apply for
Medi-Cal for your baby as soon as
possible after birth to make sure your
baby gets all the health care your baby
needs.
6534 E 0110 23
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
T. Birth Control and Other Family V. Direct Access To A Women’s
Planning Services Health Specialist
SFHP covers birth control and other If you are a female member, you can
family planning services. If you need see a women’s health specialist such as
birth control or other family planning an obstetrician/gynecologist
services, you can get them from (OB-GYN) or women’s health family
any provider who is willing to take practice physician directly for routine
Medi-Cal. You do not need to check with and preventive health care services.
your primary care provider first You can look in the Provider Directory
or get an approval. You do not need for an OB-GYN or a family practice
to see a provider who is with your physician within your medical group
medical group. You do not need to access services like pregnancy care,
the permission of your parents well-woman gynecological exams,
or guardian. primary and preventive gynecological
care and acute gynecological
If you need help finding a provider
conditions. Coverage for an annual
to help you with birth control or
cervical cancer screening test shall
family planning, call Member
include the conventional Pap test,
Services at (415) 547-7800 (local) or
human papillomavirus (HPV) screening
(800) 288-5555. You can also call the test that is approved by the federal Food
Department of Health Care Services and Drug Administration (FDA) and the
(DHCS). DHCS has people who can option of any cervical cancer screening
provide advice and give you test approved by the FDA. You do not
a list of nearby family planning clinics. need approval from another provider.
The DHCS number is (800) 942-1054. The OB-GYN or family practice
physician will share information with
U. HIV/AIDS Testing and your PCP about your condition,
Treatment For Sexually treatment and any need for follow-up
Transmitted Diseases care.
If you need HIV/AIDS testing
and/or counseling, or testing for or W. For Members Under
treatment of a sexually transmitted 18 Years of Age
disease, you can get these services If you are under the age of 18,
from any provider who is willing to take there are some important kinds of
Medi-Cal. You do not need to check with medical care you can get without
your PCP first. You do not need your parents’/guardian’s permission
to see a provider who is with your some of which are listed below.
medical group. You do not need to For these services, you also do not
get an approval. You do not need need to check with your PCP first
permission from your parents/guardian. or do not need to get prior approval.
Local Health Department confidential For most other services, your
HIV testing services are available to parents/guardian usually have
you. If you need help getting an HIV to OK any medical care you get.
test or STD test, call Member Services Some of the services you may be able
at (415) 547-7800 (local) or to get without your parents’/guardian’s
(800) 288-5555. We will provide you permission include:
with a list of confidential and alternative
test sites. You can also call the • Services related to sexual assault,
Department of Health Care Services including rape;
(DHCS). DHCS has people who can • Drug or alcohol abuse for children
provide advice and give you a list of 12 years of age or older;
nearby family planning clinics. The • Family planning services;
DHCS number is (800) 942-1054.
6534 E 0110 24
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Services related to the treatment or residential shelter services.
of sexually transmitted diseases (2) The minor (a) would present
(STDs) for children 12 years of a danger or serious physical or
age or older. mental harm to self or to others without
If you have questions about this, mental health treatment or counseling,
talk to your provider or call Member or (b) is the alleged victim of incest
Services at (415) 547-7800 (local) or child abuse.
or (800) 288-5555. You can also Family Planning and
call Planned Parenthood at Sensitive Services
(800) 230-7526 or the Adolescent
Health Working Group at Sensitive Services include services
(415) 554-8429. for diagnosis and treatment for STDs,
HIV/AIDS services and treatment for
Minor Consent Services rape or sexual assault. Family Planning
There are services that minors who and Sensitive Services can be obtained
are 12 years of age and older do not from a provider who accepts Medi-Cal.
need parental consent to receive. These Your SFHP PCP does not have to
services can be obtained from both in- authorize these services. SFHP
network and out-of-network providers will pay for all the covered Family
(who accept Medi-Cal). Minors have the Planning and Sensitive Services
right to control the disclosure of their that you may get from both an in-
medical records related to services for network or out-of-network provider (who
which they have the authority to accepts Medi-Cal). The California Office
consent. of Family Planning Information and
Referral Service can help in finding a
In California, minors 12 years and Family Planning provider. To learn
older have the authority to consent more call (800) 942-1054.
to the following services:
Note: Minors 12 years and older
Mental Health Services do have the authority to consent to
We cover mental health services that services for abortions, birth control
you get from your PCP. Services your (except sterilization), HIV testing (except
PCP can provide are limited to short- when deemed incompetent
term care in a primary care setting. to consent), rape, sexual assault,
Specialty mental health services diagnosis and treatment for pregnancy
and Short-Doyle Mental health and STDs. For sterilization, the minor's
services can be obtained through the guardian must consent and be notified
San Francisco Community Behavioral and can have access to those records.
Health Services. To learn more call Abortion services do not require pre-
approval but must be provided by an
(415) 255-3737 or (888) 246-3333.
SFHP provider contracted with your
Mental Health coverage is a limited medical group.
benefit for certain members only. See
page 47, “Medi-Cal Members That Still Treatment for Drugs and Alcohol
Have Optional Benefits” for a description Abuse (chemical dependency
of the limitations and exceptions. services)
Minors 12 years of age or older have Chemical dependency services are
the authority to consent to mental health services for alcohol or drug addiction.
treatment or counseling on an outpatient We cover services in an SFHP hospital
basis, if both of the following for medically necessary management of
requirements are satisfied: withdrawal symptoms. All other
(1) the minor, in the opinion of chemical dependency services can be
the attending professional person, accessed through the San Francisco
is mature enough to participate Community Behavioral Health Services.
intelligently in the outpatient services
6534 E 0110 25
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
To learn more, call (415) 255-3737 services. If determined to be eligible
(local) or (888) 246-3333. for CCS services, you will continue to
stay enrolled with SFHP, but will
Parental consent is not needed except receive treatment for the CCS eligible
for cases of methadone treatment. condition through the specialized
Parental/Guardian Notification network of CCS providers and CCS
approved specialty centers. SFHP
Parental or guardian notification is will continue to provide primary care
not allowed without consent of minor and preventive services that are
in abortion, birth control, pregnancy, not related to the CCS eligible
STDs, HIV testing, alcohol/drug abuse condition. SFHP will also work with
treatment and rape. For outpatient the CCS Program to coordinate care
mental health treatment, an attempt provided by both the CCS Program
should be made except when the and SFHP. The CCS Program
provider believes it is inappropriate. will provide all of the services
In cases of sexual assault, an attempt necessary to treat the CCS eligible
should be made except when the condition and SFHP will provide
provider believes parent or guardian all medically necessary covered
was responsible. services not covered by CCS.
If your child is referred to the
X. If Your Child Has Severe CCS Program, you will be asked
Medical Problems or Doesn’t to complete a short application to
Seem to Be Developing the verify residential status and ensure
Right Way coordination of your child’s care after
the referral has been made.
As an SFHP Medi-Cal member, Additional information about the CCS
you may be able to take part in other Program can be obtained by calling
programs to help you. These programs Member Services at
are from organizations other than SFHP, (415) 547-7800 (local) or
but we want to tell you about them
(800) 288-5555.
because they can be very helpful. Call
the programs directly or call SFHP if you 2. Golden Gate Regional Center
have any questions. (GGRC)
Golden Gate Regional Center
1. California Children’s
(GGRC) was created to meet
Services (CCS) the needs of people who are
California Children’s Services (CCS) developmentally disabled.
is a medical program Disabling conditions include:
that treats children with certain mental retardation, epilepsy,
physically handicapping conditions autism, cerebral palsy, Down’s
and who need specialized medical Syndrome, speech and language
care. As part of the services provided delays. GGRC helps their clients and
through the Medi-Cal Program, their families to find housing, schools,
children needing specialized medical day programs for adults,
care may be eligible for the California transportation, health care and social
Children’s Services Program (CCS). activities. Most of their services are
A Medi-Cal member must be under free to eligible clients. A member’s
the age of 21 and your PCP must primary care provider will connect
suspect or identify a possible CCS him or her with GGRC. If you have a
eligible condition. The member family member who was diagnosed
may be referred to the local CCS with a disabling condition before age
Program by the PCP or by the 18, call GGRC at (415) 546-9222.
member’s parent or guardian. You should see your PCPs if you
The CCS Program (local or the think you or your child may have a
CCS Regional Office) will determine disabling condition.
if your condition is eligible for CCS
6534 E 0110 26
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
3. Early Start to maintain clients safety in their homes
Early Start is a program for children and to avoid costly institutional care.
from birth to three years old who
need early intervention services and: The AIDS Waiver Program serves adult
• Show a developmental delay and children who meet the following
in one of the following areas: requirements:
cognitive, physical, • Are Managed Medi-Cal or Medi-Cal
communication, recipients on the date of enrollment
social/emotional,
• Have mid to late-stage HIV/AIDS
adaptive/self-help
• Are certified at the Nursing Facility
• Have a diagnosed developmental
level of care or above
disability that is expected to
continue indefinitely • Adults must have a 60 or below
performance level rating on the
• Are at high risk for a
Karnofsky acuity level scale
developmental disability
For more information about this • Children must be in category A, B or
program, call (415) 546-9222. C (i.e. mildly, moderately or severely
symptomatic) on the Centers for
4. Women, Infants and Children Disease Control Classifications
(WIC) System for HIV Infection in children
Women, Infants, and Children (WIC) under 13 years of age
is a nutrition/food program that helps • Have a safe home setting
young children and, pregnant,
postpartum (women who have just • May not be simultaneously enrolled
had a baby), or breastfeeding women in the AIDS Case Management or
to eat well and stay healthy. Children Medi-Cal Hospice programs
under five years of age, pregnant
women, women who are The PCP or Specialist submits
breastfeeding or who have just appropriate medical records and
had a baby can receive free referrals to the AIDS Waiver programs.
food vouchers, nutrition education,
and breastfeeding help. Ask your
primary care provider to help IMPORTANT NOTE: SFHP members
you apply or call to make an are NOT disenrolled in order to
appointment at (888) WIC-WORKS participate in this waiver program
or (888) 942-9675.
SFHP also offers services that can Multipurpose Senior Service Program
help you with breastfeeding your (MSSP) Waiver Program
baby. For more information on these The Multipurpose Senior Service
and other health education services, Program (MSSP) provides in-home care
contact Member Services at (415) to members as an alternative to placing
547-7800 or (800) 288-5555. them in an institution. The County’s
Department of Aging administers the
Y. Waiver Programs program. Services are available to
AIDS Waiver Program physically disabled or aged members
over 65 years of age who would
The AIDS Medi-Cal Waiver Program otherwise require care at a skilled
provides comprehensive nurse case nursing facility(SNF) or intermediate
management, home and community- care facility (ICF) level. MSSP assists
based care to Medi-Cal recipients with with a wide array of services that
mid to late-state HIV/AIDS. These include: personal housing assistance
services are provided in lieu of (nurses, home health aids, social
placement in a nursing facility or workers, senior companions), Home
hospital. The purpose of the program is Safety Modifications, Legal Assistance,
6534 E 0110 27
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Meal Delivery, Housing, Counseling and 1. In-Home Medical Care Waiver
Crisis Intervention, Transportation, (IHMC): This waiver is primarily for
Assistance with Eviction or Elder Abuse, children or adults with disabilities
Respite Care. who need acute hospital care. The
program is for persons who are
physically disabled and who, in the
The MSSP Waiver Program serves
absence of the waiver, would be
adults who meet the following
expected to require at least 90 days
requirements:
or more of acute hospital care.
• Aged 65 years or older Persons enrolled in this waiver
• Eligible with Managed Medi-Cal or program typically have a
Medi-Cal on date of enrollment catastrophic illness, may be
technology dependent, and have a
• Certifiable for skilled nursing care
that can be safely provided in the risk for life-threatening incidences.
home setting 2. Nursing Facility Waiver (NF/AB):
The medical group staff and doctors The NF/AB waiver is for persons
case manage and assist with the who are physically disabled and, in
coordination and communication of the absence of the waiver, would be
services between the MSSP and Adult expected to require at least 365
Day Health Care Center. SFHP is not days of nursing facility care at the
financially responsible for the MSSP intermediate or skilled nursing level.
services provided. A SFHP member 3. Nursing Facility Waiver (NF Sub-
who is eligible for MSSP services acute): The NF Sub-acute waiver is
remains enrolled with SFHP, and the for technology dependent adults and
medical group, and PCP maintain children (primarily adults) who are
responsibility for coordination of physically disabled and, in the
services and for continued medical care. absence of the waiver, would be
expected to require at least 180
days or more of nursing facility care
The PCP or Specialist submits at the adult sub-acute or the
appropriate medical records and the pediatric sub-acute level.
MSSP referral to the Institute on Aging,
Multipurpose Senior Service Program
and Adult Day Health Care. The PCP or Specialist submits
appropriate medical records and
referrals to Golden Gate Regional
IMPORTANT NOTE: SFHP members Center.
are NOT disenrolled in order to
participate in this waiver program
IMPORTANT NOTE: SFHP
members are NOT disenrolled in
Home and Community Based Waiver order to participate in this waiver
Programs (HCBS) program
The Home and Community Based
Waiver Programs (HCBS) keep
members out of skilled, intermediate or 3. Frequently Asked
subacute facilities. Each provides the
following services: case management, Questions
respite personal care, waiver
coordinators, private duty nursing, home
health aids, and family training.
A. What Is the Difference
Between Medi-Cal and SFHP?
There are three Home and Community
Based Waiver Programs (HCBS) SFHP is different than Medi-Cal.
Medi-Cal is the government program
that decides whether you can get your
6534 E 0110 28
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
health care paid for by the government. Your medical group decides what
If Medi-Cal says you can, you are then services require prior authorization
able to sign up for a Medi-Cal managed based on whether the services you
care health plan. SFHP is one of the want are covered and whether the
two Medi-Cal managed care health services are medically necessary.
plans in San Francisco that you can Prior authorization is the process of
join if you have Medi-Cal. SFHP does getting approval before you get access
not decide whether or not you can to medicine or services. Your medical
enroll into a managed care plan. SFHP group uses standard medical rules
delivers the health care you are entitled to decide if a service is medically
to once you qualify for enrollment in a necessary. SFHP or your medical
Medi-Cal managed care health plan group will give you a copy of the
and sign up with SFHP. information used to decide whether
the care you wanted was medically
B. Why Can’t I See Any Provider necessary.
I Want? Generally, you do not need a referral
Every primary care provider (PCP) from your PCP or an authorization for
and clinic in SFHP is part of a medical the following services:
group. A medical group is a group • Emergency services
of providers who work together.
Each medical group mainly works • OB/GYN care
with one hospital. • Family planning
When you choose a PCP, you are also • Abortion (except for the use
choosing the specialists in the PCP ‘s of general anesthesia for an
medical group and the hospital they abortion)
work with. Your PCP will refer you to • Other sensitive services
those specialists for most specialty (see page 43 for a description
care. If you have to go to the hospital, of which services these are)
you will go to the hospital that works
• Preventive care
with the PCP’s medical group.
For a complete list of services requiring
SFHP contracts with various medical prior authorization, please check with
groups. Medical groups get paid your medical group.
by SFHP when you choose them.
The payment covers the services you D. What Should I Do If I Didn’t
receive from these providers. If you go
to a different medical group provider, Get a Member ID Card, I Lost
those providers are not being paid to It, or I Don’t Want to See the
give you services even if they are a Provider Listed on the Card?
part of the SFHP network. You must SFHP mailed an SFHP member ID
see the providers that SFHP pays card to you. Show it wherever you go
to provide your services. for health care. Check the information
on your member ID card to make sure
C. What Does It Mean to Get it is correct. Call Member Services at
“Authorization”? (415) 547-7800 (local) or (800) 288-
In this Handbook, we use the words 5555 (toll free) if:
“authorize” or “authorization” to mean • You don’t want to go to the provider
getting a written OK or approval from listed on your card
your medical group, or in some cases
from SFHP, before you receive some • Any information on your member ID
services. Usually your PCP’s office card is not right
will get the authorization for you. • You move or any other information
changes
6534 E 0110 29
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Your member ID card is lost situations with a SFHP non-
or stolen contracting provider who was
You will continue to get a Medi-Cal providing services to the member
Beneficiary Identification Card (BIC) at the time the member joined
from the Department of Health Care SFHP even though this provider is
Services (DHCS). It is important to a not a part of SFHP’s network.
keep your BIC card too, but you must These health conditions include
always show your SFHP member ID acute illness, serious chronic
card when you are seeking health illnesses, pregnancies (including
services. For more information and a immediate postpartum care),
sample of your SFHP ID card, refer to terminal illness, or children from
the section, “Your Member ID Card” on birth to 36 months of age or who
page 7. have received approval from a
provider for surgery or another
procedure as part of a documented
E. What Happens If My Primary course of treatment. If the non-
Care Provider Leaves SFHP? contracted provider is not willing to
1. Continuity Of Care By A continue to provide services, then
Terminated Provider the member will not be able to
receive continued care from the
Members who are being treated non-contracted provider. Contact
for certain conditions can ask for Member Services to receive
continuation of covered services information on the process for
in certain situations with a provider requesting continuity of care
who is no longer a participating from a non-contracting provider.
provider with SFHP. These health
conditions include acute illness, Call Member Services at
serious chronic illnesses, (415) 547-7800 (local) or
pregnancies (including immediate (800) 288-5555 for more
postpartum care) and terminal information.
illness. Children from birth to 36
months of age or members who F. How Does SFHP Get Paid
have received approval from a and How Does SFHP Pay Its
now-terminated provider for
surgery or another procedure Providers and Hospitals?
as part of a documented course SFHP generally pays your medical
of treatment. If the terminated group and its hospital by a method
provider is not willing to continue called capitation. Capitation means
to provide services, then the that SFHP pays your medical group
member will not be able to receive and your hospital a set amount of
continued care from the terminated money each month. In return, your
provider. Contact Member Services medical group and hospital provide
at (415) 547-7800 (local) or (800) covered services to you at no cost
288-5555 (toll free).if you have to you. Just as SFHP gets the same
any questions or problems in amount of money from the Department
receiving covered services from a of Health Care Services whether you
provider who is no longer part of are sick that month or not, so your
SFHP. medical group and hospital get the
same amount of money each month
2. Continuity of Care for New whether you need covered services or
Members by Non-Contracting not.
Providers
While SFHP does not reward your
Newly covered members who primary care provider or medical
are being treated for certain health group if the cost of covered services
conditions can request continuation is less than an agreed upon amount,
of covered services in certain
6534 E 0110 30
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
your hospital may enter into such an (800) 288-5555. We will help you
arrangement with your medical group. figure out who has to pay the bill.
Under such an arrangement, your If you received emergency services
hospital and your medical group may and you are sent a bill for the services,
share in the cost of hospital services, you should send us a copy along with
and your medical group may receive all of your records (including your
a bonus if the cost of such services receipt of payment) within 90 days after
is below a fixed amount. you received the services, or as soon
as possible. If we don’t receive your bill
SFHP pays other providers for the
within 90 days, we may not be able to
services they deliver. However, if
pay for the services. If the services you
the total amount these providers get
are being billed were not authorized,
paid by SFHP is less than what they
SFHP will review the claim for
would have received under capitation,
coverage. SFHP will cover services
then SFHP may have to make up the
as medically necessary, or where you
difference. Similarly, if the providers
reasonably believed that an emergency
get paid more for their services than
did in fact, exist. If SFHP determines
they would have received under
that emergency services obtained by
capitation, then the providers may
youare covered, SFHP will pay the
have to pay SFHP back the difference.
providers directly or repay you if
SFHP has provider incentive programs. you have paid for these services.
SFHP’s physician incentive programs
encourage providers to provide I. Is There Any Way For Me to
preventive care services such as well-
Tell People What I Want Done
adolescent visits and well-baby visits.
You may request additional information If I Get So Sick or I Can’t Make
about these programs by calling SFHP Decisions For Myself?* (*Adapted
Member Services or contacting your from Department of Health Care
PCP, or your PCP’s medical group. Services)
Advance Health Care Directives help
G. What Happens If SFHP you to make health care decisions
Doesn’t Pay For My for yourself in case you get sick and
cannot speak for yourself. There are
Medical Care? two kinds of Advance Directives that
By law, SFHP providers must agree will help you do this.
that if SFHP does not pay the SFHP
provider for a covered service, you still The Power of Attorney for Health Care
do not owe any money. But, if you get lets you choose someone who will
services that are not covered services, make health care decisions for you
or you do not follow the authorization in case you can’t make decisions
and other rules in this Handbook, for yourself because of a serious
SFHP will not pay for the services. medical condition.
If you receive a bill for services that The Individual Health Care Instruction
you feel you should not have received, lets you write down what kind of health
please call SFHP Member Services - care services you do and don’t want
If you are unsatisfied with SFHP, you your provider to perform for you in
may file a grievance. Please see page case you get really sick. If you know
53 of the Evidence of Coverage for you wouldn’t want certain kinds of
information on how to file a grievance treatment, you can put it down in
writing so that the provider will know
H. What Should I Do If I Get a what to do in case you can’t speak
Bill For Medical Care? for yourself.
If you get a bill for medical SFHP will keep you informed regarding
services, call Member Services any changes to California state law
at (415) 547-7800 (local) or at regarding advance directives as
6534 E 0110 31
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
soon as possible, but no later than Yes. You may tell your provider that
90 calendar days after the effective you want someone else to make
date of change. health care decisions for you. Ask
the provider to list that person as
Please read the following information
your health care “surrogate” in your
about Advance Directives:
medical record. The surrogate’s
1. Who Decides About control over your medical decisions
My Treatment? is effective only during treatment of
your current illness or injury or, if
Your providers will give you you are in a medical facility, until
information and advice about you leave the facility.
treatment. You have the right
to choose. You can say “yes” to 5. What If I Become Too Sick to
treatment you want. You can say Make My Own Health Care
“no” to any treatment that you don’t Decisions?
want—even if the treatment might
If you haven’t named a surrogate,
help you to recover faster or keep
your provider will ask your closest
you alive longer.
available relative or friend to help
2. How Do I Know What I Want? decide what is best for you. Most of
the time that works. But sometimes
Your provider must tell you about
everyone doesn’t agree about what
your medical condition and about
to do. That’s why it is helpful if you
what different treatments and pain
can say in advance what you want
management choices can do for
to happen if you can’t speak
you. Many treatments have “side
for yourself.
effects.” Your provider must offer
you information about problems 6. Do I Have to Wait Until I am Sick
that medical treatment is likely to Express My Wishes About
to cause you. Health Care?
Often, more than one treatment No, in fact, it is better to choose
might help you and people have the kind of treatment you would like
different ideas about which is best. before you get very sick or have to
go into a hospital, nursing home, or
Your provider can tell you which
other health care facility. You can
treatments are available to you, but
use an Advance Health Care
your provider can’t choose for you.
Directive to say who you want
That choice is yours to make
to speak for you and what kind
and it depends on what is
of treatments you want. These
important to you.
documents are called “advance”
3. Can Other People Help because you prepare one before
with My Decisions? health care decisions need to be
made. They are called “directives”
Yes. Patients often turn to their
because they state who will speak
relatives and close friends for help on your behalf and what should
in making medical decisions. These
be done.
people can help you think about the
choices you face. You can ask the In California the part of an Advance
providers and nurses to talk with Directive you can use to appoint
your relatives and friends. They can an agent to make health care
ask the doctors and nurses decisions is called a Power of
questions for you. Attorney for Health Care. The part
where you can express what you
4. Can I Choose a Relative or Friend want done is called an Individual
to Make Health Care Decisions Health Care Instruction.
For Me?
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
7. Who Can Make an You can change or cancel your
Advance Directive? Advance Directive at any time as
long as you can communicate your
You can if you are 18 years or older wishes. To change the person you
and are capable of making you own want to make your health care
medical decisions. You do not need decisions, you must sign a
a lawyer. statement or tell the provider
8. Who Can I Name as My Agent? in charge of your care.
You can choose an adult relative or 13. What Happens When Someone
any other person you trust to speak Else Makes Decisions About
for you when medical decisions My Treatment?
must be made.
The same rules apply to anyone
9. When Does My Agent Begin who makes health care decisions
Making My Medical Decisions? on your behalf—a health care agent,
a surrogate whose name you gave
Usually a health care agent will to your provider. Or a person
make decisions only after you lose appointed by a court to make
the ability to make them yourself. decisions for you. All people
But, if you wish, you can state in the speaking on your behalf are
Power of Attorney for Health Care required to follow your Health Care
that you want the agent to begin Instructions or, if you have left no
making decisions immediately. Health Care Instructions, your
10. How Does My Agent Know general wishes about treatment,
What I Would Want? including stopping treatment.
If your treatment wishes are not
After you choose your agent, talk known, the surrogate must try to
to that person about what you want. decide what is in your best interest.
Sometimes treatment decisions are
hard to make, and it truly helps if The people providing your health
your agent knows what you want. care must follow the decisions of
You can also write your wishes your agent or surrogate unless
down in your Advance Directive. a requested treatment would be
bad medical practice or ineffective
11. What If I Don’t Want to in helping you. If this causes
Name An Agent? disagreement that cannot be
You can still write out your wishes worked out, the provider must
in an Advance Directive, without make a reasonable effort to find
naming an agent. For example, you another health care provider
can say that you want to have your to take over your treatment.
life continued as long as possible, 14. Will I Still Be Treated If I Don’t
or you can say that you would not Make an Advance Directive?
want treatment to continue your life.
Also, you can express wishes about Absolutely. You will still get medical
the use of pain relief or any other treatment. You are not required to
type of medical treatment. fill out an Advance Health Care
Directive. We just want you to know
Even if you have not filled out that if you become too sick to make
a written Individual Health Care decisions, someone else will have
Instruction, you can discuss your to make them for you.
wishes with your family members
or friends. But, it will probably be Remember that:
easier to follow your wishes if you • A Power of Attorney For Health
write them down. Care lets you name an agent
12. What If I Change My Mind? to make decisions for you. Your
agent can make most medical
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
decisions—not just those about • Family planning services
life sustaining treatment—when and most sensitive services.
you can’t speak for yourself. Look on page 36, to learn more.
You can also let your agent • Care at an Indian Health Center.
make decisions earlier if Look on page 12, to learn more.
you wish.
Keep in mind that if you have questions,
• You can create an Individual call Member Services at (415) 547-7800
Health Care Instruction by (local) or (800) 288-5555, or for the
writing down your wishes about hearing impaired, call (415) 547-7830 or
health care or by talking with
(888) 883-7347 (TDD). We can answer
your provider and asking the
your questions Monday through Friday,
provider to record your wishes
from 8:30am to 5:30pm.
in your medical file. If you know
when you would or would not
want certain types of treatment, A. Hospital Inpatient Care
an Instruction provides a good Hospital inpatient cares are services
way to make your wishes clear to that you get when you are admitted
your provider and to anyone else to a SFHP hospital. We cover:
who may be involved in deciding
• A room you share with one
about treatment on your behalf.
or more people
These two types of Advance
Health Care Directives may • A private room, if medically
be used together or separately. necessary
• Meals
15. How Can I Get More • Special care units
Information About Making • Services of SFHP providers
an Advance Directive?
• Nursing services
Ask your doctor, nurse, social • Anesthesia
worker, or healthcare provider
to get more information for you. • Operating room and related services
You may also contact Member • Medical supplies
Services at (415) 547-7800 (local) • Blood and blood products
or (800) 288-5555. *Adapted
from Department of Health Care • Respiratory therapy
Services. • Planning for care after you leave
the hospital
We also cover other hospital services
4. Care That SFHP Covers only as further described in this
“Care That SFHP Covers” section.
Remember, if you have an emergency
medical condition, you may be
This part tells you about services that we admitted to any hospital and treated
cover. Services described in this section by any provider. Look in these
are covered only if all of the things below headings to learn more:
are true:
• Chemical Dependency Services
• The services are medically necessary on page 36
• To the extent required by your medical • Dialysis Care on page 36
group, the medical group OKs
(authorizes) the services, except that • Durable Medical Equipment
you do not need an approval for: on page 36
• Emergency care. Look in the • Health Education on page 37
Emergency Medical Care section • Hospice Care on page 38
on page 20 to learn more.
6534 E 0110 34
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Imaging and Lab Services cervical cancer and breast cancer
on page 39 (“mammograms”).
• Medical Transportation on • Services when you are sick or hurt
page 39 • Services when you are pregnant
• Ostomy and Urological Supplies (“prenatal care”) and after you have
on page 40 your baby (“postpartum care”)
• Pharmacy Services on page 41 • Specialty care visits
• Prosthetic Devices and Orthotic • Outpatient surgery
Devices on page 42 • Anesthesia
• Reconstructive Surgery on • Respiratory therapy
page 43
• Blood and blood products
• Services Related to Clinical Trials
on page 44 • Medical social services
• Skilled Nursing Facility Care • House calls in San Francisco when
on page 44 your SFHP PCP finds that you can
best get services in your home
• Therapy and Rehabilitation Services
on page 45 • Emergency care
We also cover other outpatient services
• Transplant Services on page 45
only as described in this “Care That
SFHP Covers” section.
B. Labor and Delivery
Look at these headings to learn more:
SFHP covers inpatient labor
and delivery services. • Dialysis Care on page 36
Your SFHP PCP may order follow-up • Durable Medical Equipment
visits if you go home sooner than: on page 36
• 48 hours after delivery • Family Planning Services
on page 36
• 96 hours after a cesarean section
• Health Education on page 37
C. Outpatient Care • Hearing Services on page 37
Outpatient care is service that you get: • Home Health Care on page 38
• Hospice Care on page 38
• In a SFHP provider’s office/
in a SFHP clinic • Imaging and Lab Services
on page 39
• In a SFHP hospital, when
you have not been admitted • Medical Transportation
to the hospital on page 39
These can be services: • Mental Health Services
on page 40
• To keep you from getting sick
(“preventive care”) • Ostomy and Urological Supplies
on page 40
• To find out what is wrong
(“diagnosis”) • Pharmacy Services on page 41
• When you are sick or hurt • Prosthetic and Orthotic Devices
(“treatment”) on page 42
We cover: • Reconstructive Surgery on
• Primary care visits, such as page 43
well-child care, including services • Sensitive Services on page 43
covered by CHDP (Child Health • Services Related to Clinical Trials
and Disability Prevention Program), on page 44
well-adult care, including tests for
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Therapy and Rehabilitation Services Following our formulary and Medi-Cal
on page 45 guidelines, we cover DME for use in:
• Transplant Services on page 45 • Your home (or an institution
• Vision Services on page 46 used as your home)
• A SFHP hospital
D. Chemical Dependency • A skilled nursing facility
Services • Coverage is limited to the lowest
Chemical dependency services are cost DME that meets your
services for alcohol or drug addiction. medical needs.
We cover services in an SFHP hospital Keep in mind:
for medically necessary management
of withdrawal symptoms. • We decide whether to rent or buy
the DME, and whom we will rent
Exclusions: We do not cover any or buy it from
other chemical dependency services.
• We will fix or replace DME unless
You must get these services from the
you lose or misuse it
San Francisco Community Behavioral
Health Services. To learn more, call • You must give the DME back
toll free at (888) 246-3333. to us when we are no longer
covering it
If you are age 12 and over, your parent
Exclusions: We do not cover:
does not have to give approval for you
to use these services. • Comfort or convenience items
• Luxury items
E. Dialysis Care • Items used for exercise
We cover equipment and supplies if:
• Items used for hygiene (unless
• The services are provided in Medi-Cal criteria have been met.
San Francisco (unless it is an SFHP will cover incontinence
emergency or an urgent creams and washes when there is a
out-of-area need) medical need)
• You meet all medical criteria created • Household or furniture items
by your medical group and by the • Changes to your home or car
facility providing the dialysis
• Items that test blood or
• The facility is certified by Medicare other fluids (except blood
We will also cover training needed for glucose monitors)
home dialysis, if you are able to receive • Items that monitor the heart
your dialysis at home or lungs (except infant
apnea monitors)
F. Durable Medical Equipment • More than one item of DME
(DME) that does the same thing
DME is something that is:
• For repeat use
G. Family Planning Services
Family planning services are medically
• Used for a medical purpose
necessary services that prevent or
• Not useful to someone who delay pregnancy. If you are age 12
is not ill or hurt and over, your parent does not have
• Safe for use in the home to give approval for you to get family
We cover durable medical equipment planning services. Family planning
(DME) that is authorized and includes birth control and testing
prescribed by your SFHP provider. for pregnancy, sexually transmitted
diseases and HIV testing and
counseling.
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
We cover the visits to talk about • Any special foods or diet items.
family planning services options The Women, Infants and Children
as well as the services listed below: (WIC) Program is a nutrition/food
• Birth control drugs and items. Look program that helps young children and
under “Pharmacy Services” on page women to eat well and stay healthy.
41 in this “Care That SFHP Covers” Children under five years of age,
section to learn more. pregnant women, women who are
breastfeeding or who have just had a
• Care for medical problems related baby should call WIC to get free food
to birth control methods. vouchers, nutrition education, and
• Lab services related to covered breastfeeding support. Ask your PCP
family planning services. Look under to help you apply or call to make an
“Imaging and Lab Services” on page appointment at (888) WIC-WORKS
39 in this “Care That SFHP Covers” or (888) 942-9675.
section to learn more.
• Surgical birth control (called I. Health Education
“tubal ligation” for women and We cover programs that can help
“vasectomy” for men) you protect and improve your health.
• Pregnancy tests and counseling This includes programs to help you:
You can get family planning services • Stop smoking
from an SFHP provider. You can also
get family planning services from a • Manage stress
non-SFHP provider that accepts • Live better with a chronic
Medi-Cal. condition like asthma, diabetes,
or heart disease
• Your PCP does not have to
OK (authorize) these services To find out more, call Member Services
and ask for the Health Education
• We will pay the non-SFHP provider Department at (415) 547-7800 (local)
for the covered services you get or (800) 288-5555, or log on to
Call California Office of Family http://www.sfhp.org.
Planning Information and Referral
Service’s toll free number at J. Hearing Services
(800) 942-1054 if you want help in
finding a provider. 1. Hearing Tests
SFHP covers Audiology (hearing
H. Food/Vitamins/Diet Items tests) for members when there is a
We only cover: medical need.
• Nutritional supplements and We cover tests to find out:
formulas for the treatment of
• If you need a hearing aid
Phenylketonuria (PKU) when they
are prescribed for you by your • Which hearing aid will be
primary care provider or specialist. best for you
• Nutritional supplements or 2. Hearing Aids
replacements (called “enteral We cover, when prescribed by an
formula”) to prevent sickness or SFHP provider or audiologist:
death if you cannot take any regular,
blended, or pureed food by mouth. • One hearing aid, or
• One aid for each ear, if both
• SFHP covers medically necessary are needed as determined by
infant formulas when prescribed by an audiologist
a provider. We cover a new aid, if:
Exclusions (we do not cover):
6534 E 0110 37
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Your hearing loss is such that • Part-time skilled nursing care
your current aid is not able to • Part-time home health aide
correct it
• Medical social services
• Your aid is lost, stolen, or broken
(and cannot be fixed), and it was • Medical supplies
not your fault. You must give We also cover other home health
us a note that tells us how services in accord with other parts of
this happened this “Care That SFHP Covers” section.
We also cover: Look under these headings to
learn more:
• Visits to make sure that the
aid is working right • Durable Medical Equipment, page
• Visits for fitting and cleaning 36
• Repair of your aid • Ostomy Supplies and Urological
Supplies, page 40
• Initial hearing aid batteries
• Pharmacy Services, pages 41 and
Keep in mind: 42
• We will choose who will • Therapy and Rehabilitation
supply the aid Services, page 45
• Coverage is limited to the • Prosthetic Devices and Orthotic
lowest cost aid that meets Devices, page 42
your medical needs Exclusions: We do not cover:
Exclusions: We do not cover:
• Personal care services
• Comfort and convenience items
• Aids that are implanted L. Hospice Care
• Replacement batteries. Members who are dying can choose
For members under the age to get hospice care for their terminal
of 21, EPSDT Supplemental; illness. This care:
Services does cover quarterly
replacement of certain hearing • Helps the discomforts of
aid batteries. someone who is dying
• Also helps that person’s
K. Home Health Care caregiver and family
We cover home health services only: Keep in mind:
• In San Francisco • If you choose to get hospice care,
you get care to relieve pain and
• If you are housebound other symptoms, but not to cure
(“substantially confined” your terminal illness
to your home)
• You can change your decision
• If a SFHP provider finds that it to get hospice care at any time
is possible to monitor your care
We cover hospice care only if:
in your home
• A SFHP provider finds that you
• Home health services are medically
have a terminal illness and you
necessary services that:
are expected to live 12 months
• Are prescribed by a or less, and
SFHP provider
• The services are provided in
• Can be provided by home health San Francisco by a hospice agency
staff in a safe and effective way approved by your medical group.
in your home
If the above requirements are met, we
Home health services are limited to cover the following hospice services,
services that Medi-Cal covers, such as:
6534 E 0110 38
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
which are available on a 24-hour basis We cover imaging:
as needed:
• To keep you from getting sick
• Services of SFHP providers (“preventive care”)
• Skilled nursing care, such as • To help find out what is wrong
evaluation and case management (“diagnostic imaging”)
of nursing needs, treatment for pain
and symptom control, emotional • For treatment (“therapeutic
support for you and your family, imaging”)
and instructions for caregivers We cover lab services ordered by a
SFHP provider. This includes tests for
• Physical therapy, occupational
genetic disorders for which you can
therapy, or speech therapy for
get genetic counseling. Fetal genetic
symptom control or to help you
screening and counseling are covered.
maintain activities of daily living
We cover lab services ordered by a
• Respiratory therapy non-SFHP provider only if the services
• Medical social services are related to:
• Home health aide and help with • Specialty mental health services
eating, bathing, and dressing and Short-Doyle Mental Health
We cover drugs for pain control and Services. Look in the “Mental Health
to help with other symptoms of your Services” section on page 40
terminal illness: to learn more
• In accord with our drug formulary • Covered family planning services.
guidelines Look in the “Family Planning
Services” section on page 36,
• You must get these drugs from a
to learn more.
SFHP pharmacy or another
pharmacy we choose • Emergency Medical Condition
• For some drugs we cover a 30-day We cover other tests, such
supply in any 30 day period as those that check the heart
(“electrocardiograms”) or brain
We also cover:
(“electroencephalograms”). We also
• Durable medical equipment (DME) cover UV (“ultraviolet”) light treatment.
• Respite care when needed to
relieve your caregivers. Respite N. Medical Transportation
care is occasional short term
1. Ambulance Services
inpatient care limited to no more
than five consecutive days We cover emergency ambulance
at a time services that are not ordered by
• Counseling to help with loss us if you reasonably believe all
of the following:
• Advice about diet
• Nursing care at home (for as much • You are experiencing acute
as 24 hours a day) or short-term symptoms of sufficient severity
inpatient care (at a level that cannot (including severe pain), such that
be provided at home) during periods a prudent layperson, who has an
of crisis when you need continuous average knowledge of health and
care for pain control or management medicine could reasonably
of acute medical symptoms expect the absence of immediate
medical attention to result in:
M. Imaging and Lab Services • Placing the health of the
individual (or, in the case of a
We cover imaging and lab services pregnant woman, the health of
only if they are related to other covered the woman or her unborn child)
services (except as noted below). in serious jeopardy, or
6534 E 0110 39
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Serious impairment to bodily the scope of practice of Primary Care
functions, or Physicians) or Short-Doyle Mental
• Serious dysfunction of any Health Services (community mental
bodily organ or part health services). However, we cover
related services in accord with other
• Your condition requires parts of this “Care That SFHP Covers”
ambulance transport section. Look under these heading
We also cover ambulance services to learn more:
if a SFHP provider finds that the
use of any other kind of transport • Pharmacy Services on page 41
might harm your health. A SFHP • Imaging and Lab Services
provider must OK (authorize) these on page 39
services in writing. Exclusions: We do not cover:
Please discuss your transportation • Specialty mental health
needs with your provider or call services and Short-Doyle Mental
Member Services at (415) 547-7800 Health Services. You must get these
(local) or (800) 288-5555 from services through the San Francisco
Monday through Friday, 8:30am Community Behavioral Services.
to 5:30pm. To learn more, call toll at
(415) 255-3737 (local) or (888) 246-
2. Other Medical Transportation
3333 (toll free).
Services
• Services that are not provided
We cover a wheelchair van or in a medical setting (“residential
gurney van, if: treatment”)
• A SFHP provider finds that Mental Health coverage is a limited
transport by car, taxi, or bus benefit for certain members only. See
might harm your health, and page 47“Medi-Cal Members That Still
• A SFHP provider transport Have Optional Benefits” for a
is medically necessary, and description of the limitations and
exceptions.
• The transport is to get to a SFHP
provider or facility for covered
services
P. Ostomy and Urological
Supplies
Exclusions: We do not cover:
Ostomy supplies are medically
• Transport by car, taxi, or bus,
necessary supplies that take waste
even if it is the only way to
out of the body. Urological supplies
get to a SFHP provider
are medically necessary supplies that
• Non-medical transportation capture urine outside the body. We
is not covered. cover ostomy and urological supplies
that are prescribed in accord with our
O. Mental Health Services durable medical equipment formulary
We cover mental health services that and Medi-Cal guidelines.
you get from your PCP: We cover ostomy and urological
supplies for use in:
• Services your PCP can provide
are limited to short-term care in • Your home
a primary care setting • A SFHP hospital
• If you are age 12 and over, • A SFHP medical office
your parent does not have to
give approval for you to get • A skilled nursing facility
these services • We select from whom we will buy
We do not cover specialty mental the supplies. Coverage is limited to
health services (services outside
6534 E 0110 40
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
the lowest cost item that meets your T. Insulin-Administration
medical needs. Devices
Exclusions: We do not cover:
We cover:
• Comfort or convenience items
• Disposable needles, lancets, lancet
• Luxury items puncture devices, syringes and
insulin pumps
Q. Pharmacy Services • Pen devices
We cover the drugs, supplies, and
• Visual aids needed to see
supplements per the following:
the dose
• When prescribed by a SFHP • Glucose monitors for the
provider (except as noted under visually impaired
“Outpatient Drugs” on page 41)
• In accord with SFHP U. Birth Control Drugs and
and Medi-Cal under Devices
“Food/Vitamins/Diet Items”
on page 37 We cover prescription and OTC drugs
and devices including, but not limited
• In accord with SFHP formulary to:
(list of approved drugs) guidelines
• Emergency contraception, • Birth control drugs that go
dispensed by a pharmacist under the skin
Keep in mind; you must get these • Birth control pills
drugs and items from a SFHP • Emergency contraceptive pills
pharmacy. • IUDs (“intrauterine devices”)
• Diaphragms
R. Administered Drugs
• Cervical caps
Administered drugs, supplies, and
supplements are drugs or items: • Condoms
• You get in a SFHP hospital
V. Outpatient Drugs
or a skilled nursing facility
We cover drugs, supplies, and
• You get in a SFHP provider office or supplements when medically
during home visits, when the drug necessary and covered under your
must be given (“administered”) by SFHP benefit plan. The following
health staff items are covered when prescribed
• You give to yourself at home by a SFHP provider:
We cover: • Prescription drugs
• Vaccines and shots • Medical supplies
(“immunizations”)
• Nutritional supplements in
• Allergy tests and treatments select circumstances as
• Drugs that must be infused listed on page 37
• Other drugs that Medi-Cal
S. Diabetes Urine-Testing covers, such as vitamins
Supplies when you are pregnant
We cover: • Drugs to help you stop smoking,
if you take part in a health education
• Test strips program that we approve
• Test tablets or tapes • Disposable needles needed
for covered drugs
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Special packaging of drugs for You must be getting the drug for a use
example easy-open containers approved by the FDA (Food and Drug
• Medically necessary drugs needed Administration)
to treat a complication from a • You can get drugs that are not on
service the list if SFHP finds that the drug
that is not covered is medically necessary
We also cover medically necessary • You must take part in a health
drugs prescribed by these non-SFHP education program for some
providers when covered under your conditions
SFHP benefit plan:
• You must use a generic form of a
• Drugs related to dental care brand-name drug when a generic
that are prescribed by dentists is available
• Drugs related to covered emergency Exclusions:
care. Look in the “Emergency Care”
section on page 11, to learn more We do not cover drugs related to
services that are not covered.
• Drugs and items related to covered
family planning services. Look in the If a drug is no longer covered, we will
“Family Planning Services” section keep giving it to you until your SFHP
on page 36, to learn more. provider stops prescribing it for the
• Drugs related to specialty mental same condition. You must be getting
health services and Short-Doyle the drug for a use approved by the
Mental Health Services. Look FDA (Food and Drug Administration).
in the “Mental Health Services” For more information, call Member
section on page 40, to learn more. Services at (415) 547-7800 (local) or
(800) 288-5555 from Monday through
W. Our Drug Formulary Friday, 8:30am to 5:30pm.
Our drug formulary is a list of
drugs that have been approved X. Prosthetic and Orthotic
by our Pharmacy and Therapeutics Devices
Committee for our members. Prosthetic devices are medically
The Pharmacy and Therapeutics necessary items that replace all or part
Committee: of an organ or limb. Orthotic devices
• Picks drugs for the list based on are medically necessary items that
how safe the drug is and how support or correct a body part.
well it works We cover the prosthetic and orthotic
• Meets every three months to see if devices if they are:
drugs need to be added or taken
off the list • In general use
• Makes changes to the list if there • For repeat use
are new facts about a drug or if • Used for a medical purpose
there is a new drug • Not useful to someone who is
Our drug formulary guidelines say: not ill or hurt
• Drugs listed in the formulary must Coverage is limited to the lowest cost
be tried and failed before SFHP item that meets your medical needs.
can approve a non-formulary drug Keep in mind:
• Limits may apply to formulary • We cover services to find out
agents. Some examples of limits if you need an item
include member age, amount of • We decide who will supply and
medicine, and dosage form (tablet, repair the item
liquid, capsule, cream) limits
6534 E 0110 42
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• We cover visits to fit and adjust AA. Reconstructive Surgery
the item SFHP covers reconstructive surgery
• We will fix or replace the item that corrects or repairs problems with
unless you lose or misuse it parts of the body that are caused by
birth defects, abnormal development,
Y. Internally Implanted Devices trauma, infection, tumors, or disease.
We cover items implanted during a
covered surgery. The item must be BB. Mastectomy
approved by the FDA (Food and After medically necessary removal of
Drug Administration) for general use. all or part of a breast (a“mastectomy”),
Please see page 56 for information on we cover:
having the DMHC review a denial of an
experimental or investigational device • Reconstructive surgery
under the IMR process. of the breast
• Reconstructive surgery of
Z. External Devices the other breast for a more
similar look
We cover:
• Services for swelling after lymph
• Prosthetic devices to restore a nodes have been removed
way of speaking after all or part (“lymphedema”).
of the larynx has been removed
Exclusions: We do not cover surgery:
• Breast prostheses after a
• If a SFHP provider finds that it will
breast has been removed
cause only a small change in how
(a “mastectomy”), including
you look
custom-made items when
medically necessary and up • On normal parts of the body
to three bras per year to change how you look
• Medically necessary footwear to
prevent or treat problems related CC. Sensitive Services
to diabetes We cover:
• Burn wraps and wraps for swelling • STD (“sexually transmitted disease”)
after lymph nodes have been services
removed (“lymphedema”)
• HIV/AIDS services
• Prosthetic devices needed
to replace an organ or limb • Services for victims of
sexual assault
• Orthotic sevices needed to
support or correct a body part • Family planning services
(as described under “Family
• Braces and special shoes if Planning Services,” on page 36)
they are attached to the brace
• Abortions
Exclusions: We do not cover:
If you are age 12 and over, your parent
• Prosthetic and orthotic devices does not have to give approval for you
related to services that are to get these services.
not covered
1. STD Services
• Items that are not rigid, such
as stockings and wigs (unless SFHP covers STD services from a
Medi-Cal criteria have been met) SFHP provider
• Comfort or convenience items or a non-SFHP provider that
accepts Medi-Cal:
• Luxury items
• Shoes or arch supports that • Your PCP does not have to
are not medically necessary OK (authorize) these services
6534 E 0110 43
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• We will pay the non-SFHP DD. Services Related to
provider for the covered Clinical Trials
services you get
We cover services that are related
• If a Gonorrhea or Chlamydia to a cancer clinical trial if:
diagnosis is made at the first visit
with either a SFHP provider or a • You have been diagnosed
non-SFHP provider, SFHP will with cancer
help you get care with a SFHP • You are accepted into a clinical
provider for treatment. trial for cancer
• If not presumptively diagnosed • The SFHP provider who is treating
and treated at the time of the first you believes that the clinical trial
visit but found to have Gonorrhea will benefit you
or Chlamydia by either a SFHP
provider or a non-SFHP provider, • The services are covered
a second visit to a SFHP provider in this booklet
or a non-SFHP provider will be • The clinical trial is to treat cancer
covered. and not just to find out if a drug
• For all other STD’s, SFHP will is safe
cover additional visits with SFHP The clinical trial must:
providers and through the Local • Involve a drug that does not
Health Department. need a new drug application, or
• Be approved by the National
2. HIV/AIDS Services Institutes of Health, the FDA (Food
and Drug Administration), the
We cover the first visit for HIV/AIDS Department of Defense, or the
testing and consultation from a Veterans’ Administration
SFHP provider or from a non-SFHP
provider that accepts Medi-Cal. Exclusions: We do not cover:
• Your PCP does not have to • Services that are provided only
OK (approve) these services for data collection and analysis
• We will pay the non-SFHP • Services that someone in a clinical
provider for the covered trial usually gets from the sponsors
services you get of the trial free of charge
• If you need follow-up services, • Services related to drugs or items
you must get these services that have not been approved by the
from a SFHP provider. FDA. Please see page 56 for
information on having the DMHC
3. Abortions review a denial of an experimental
We cover abortions that you get or investigational device or therapy
from a SFHP provider in your under the IMR process.
medical group or from a non-
network provider. Prior EE. Skilled Nursing Facility Care
authorization for outpatient We cover services in a skilled nursing
abortions is not required. Inpatient facility that we contract with only when:
hospitalization for abortions may be
subject to prior authorization • Services are medically necessary
procedures as per our current • Services are prescribed by
policies and procedure specific to a SFHP provider
each medical group and hospital
contract • You do not need to be in a hospital
to get the services
• Services are for the month of
admission plus the next month
6534 E 0110 44
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
The services must be at a level of care authorize the services for a limited
that people normally get in a skilled period of time and then require a
nursing facility including: reevaluation before issuing
additional approvals. Children three
• Skilled services years or older are referred to their
• Subacute services, in accord school districts for speech therapy
with Medi-Cal standards services, physical and occupational
• Custodial care services, in accord therapy. SFHP will work with the
with Medi-Cal standards school districts to coordinate care.
We cover: We only cover these services:
• Services of SFHP providers • In a SFHP hospital
• Nursing services • In a skilled nursing facility
• Room and meals that we contract with
• Medical social services • As part of home health care
• Blood and blood products Limitation: Occupational therapy
is limited to services for better
• Medical supplies self-care and activities of daily
• Therapy and rehabilitation services living which help you to live
as part of a care plan independently.
We also cover services in accord with 2. Rehabilitation Services
other parts of this “Care That SFHP
Covers” section on page 34. Look We cover medically necessary
under these headings to learn more: services in a special rehabilitation
services program when:
• Durable Medical Equipment
on page 36 • A SFHP provider prescribes
the services
• Imaging and Lab Services
on page 39 • In a SFHP facility
• Pharmacy Services on page 41 • In a skilled nursing facility
that we contract with
If you need skilled nursing facility care
longer than the month of admission
plus the next month, you must get this GG. Transplant Services
care through regular Medi-Cal with the We cover kidney and corneal
exception of hospice services that are transplants if:
not considered long term regardless of
the length of stay in a nursing facility. • You are age 21 or older
Timeframes do not apply for members • Your medical group gives an OK
who have elected hospice that are in a (authorizes) for your transplant at
nursing home. Look in the “Termination a transplant facility. Look under
of Coverage” Section on page 51, to “Getting a Referral” and
learn more. “Authorization Procedure” in the
“How to Get Care” section on page
FF. Therapy and Rehabilitation 19, to learn more.
Services • If you are under the age of 21, your
transplant will be provided
1. Physical Therapy, Occupational
by California Children Services
Therapy, and Speech Therapy
(CCS). Please see page 26 for a
We cover physical therapy, complete description of how the
occupational therapy, and speech Plan coordinates care with CCS.
therapy when a SFHP provider Keep in mind:
prescribes the services and they
are medically necessary. We may • If your medical group or the referral
facility finds that you
6534 E 0110 45
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
do not meet the criteria for a • Services that we do not
transplant, we will pay only cover (“Exclusions”)
for services you get before • Limits to services that we cover
that finding is made (“Limitations”)
• We are not responsible for making This section also tells you what happens:
sure an organ is available
Also, we cover certain services for a • If you have other health care coverage
donor for you or someone your medical • If another source must pay for services
group finds might be a donor for you that we cover (“Reductions”)
(even if they are not a member). Exclusions: The services listed below are
These services must be: not covered by us. They may be covered
• In accord with our rules by another program. In some cases, like
for donor care CCS (California Children’s Services),
your SFHP provider may refer you to
• For your covered transplant a non-SFHP provider. If the services
Exclusions: We do not cover any are covered by regular Medi-Cal:
other transplant services, such as lung,
heart, liver, heart/lung, or any other • Find a Medi-Cal provider who
organ transplant. You must get these offers the services
services through regular Medi-Cal or • Bring your Medi-Cal member ID card
CCS (California Children’s Services). when you go to that provider
Please call Member Services at (415) Keep in mind that when something is
547-7800 (local) or (800) 288-5555 for not covered, all related services are not
any questions. covered. The only exception is that we
cover certain medically necessary
HH. Vision Services services related to:
Vision services are covered by Vision • Dental care (see “Dental Care,”
Service Plan (VSP). For vision on page 48)
services, SFHP members who are
• Specialty mental health services and
children under the age of twenty one
Short-Doyle Mental Health Services.
(21) or adults age twenty one (21) and
Look under “Mental Health Care” in
older with diabetes are automatically
the “Care That SFHP Covers” section
enrolled in VSP. Generally, services
on page 40 to learn more.
are not covered for adults age twenty
one (21) and older. SFHP does cover
medically necessary eye examinations, Due to a change in California law, starting
from an ophthalmologist, for all July 1, 2009, Medi-Cal will be reducing
members. For more information about benefits. This change will affect Medi-Cal
the vision plan, Contact VSP toll free at beneficiaries age 21 and older. See page
(800) 438-4560. Vision coverage is a 47, “Medi-Cal Members That Still Have
limited benefit for certain members Optional Benefits” for exceptions.
only. See page 47, “Medi-Cal
Members That Still Have Optional Benefits will not change for those less
Benefits” for a description of the than 21 years old.
limitations and exceptions. Medi-Cal will no longer pay for the following
benefits and services for most adults (there
are some exceptions):
5. Care That SFHP Does • Dental services
Not Cover • Speech therapy services
• Podiatric services
This section tells you about: • Audiology services
6534 E 0110 46
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Chiropractic services may also be available up to 60 days
after the baby is born); or
• Acupuncture services
• Receiving benefits through the
• Optometric and optician services California Children’s Services program;
(ophthalmology [doctor services for the or
eyes] will continue to be covered)
• Receiving benefits through a Program
• Psychology services (psychiatric of All-Inclusive Care for the Elderly; or
services, and all services through
county mental health programs will • Receiving hospital outpatient services;
continued to be covered) or Receiving services provided by a
physician.
• Incontinence creams and washes
For further information on the Medi-Cal
While the Medi-Cal program will no longer reduction of benefits, please call SFHP
cover the benefits and services for most Member Services at (415) 547-7800 (local)
adults as listed above, SFHP will still provide or (800) 288-5555 (toll free).
you, at no cost, the following services when
your doctor or clinic decides these benefits In addition to exclusions and
are needed: limitations of previous sections,
SFHP also does not cover:
• Speech therapy services
• Podiatric services A. Acupuncture Services
• Audiology services Acupuncture is the procedure of
inserting needles into various points of
• Incontinence creams and washes the body to relieve pain or for therapy.
• Vision services for diabetic members You must get these services through
only. Services covered include annual regular Medi-Cal. Acupuncture
eye exam only. Frames, lenses, and services are a limited benefit for certain
contact lenses are not covered. members only and are generally not
covered for adults age twenty one (21)
6. Medi-Cal Members That and older. See page 47, “Medi-Cal
Members That Still Have Optional
Still Have Optional Benefits” for a description of the
Benefits limitations and exceptions.
B. Adult Day Health Care
The above benefits and services will NOT Services you get through an adult
change for Medi-Cal beneficiaries who are: day health care program.
• Under the age of 21; 0r
C. Case Management Services
• Living in a skilled nursing facility (Level Case management services that are
A or B; this includes sub-acute care for lead poisoning case management
facilities; or are not covered. You must get these
• Pregnant. (If you are pregnant you can services from the San Francisco
continue to receive pregnancy-related Department of Public Health.
benefits and services. You can also Call them at (415) 863-9892.
receive other benefits and services
listed above to treat conditions that, if D. CCS Services
left untreated might cause difficulties in Services you get through CCS
the pregnancy. This includes dental (California Children’s Services).
exams, cleanings and gum treatment. To learn more about CCS,
Dental and other benefits and services see page 26.
6534 E 0110 47
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
H. Exams and Services
Services needed:
E. Chiropractic Services
• To get or keep a job
Chiropractic services are used for the
treatment and prevention of • To get insurance
mechanical disorders of the • To get any kind of license
musculoskeletal system, especially the
• By order of a court, or if for
spine.
parole or probation
You must get these services This exclusion does not apply if an
through regular Medi-Cal. Chiropractic SFHP provider finds that the services
services are a limited benefit for certain are medically necessary.
members only and are generally not
covered for adults age twenty one (21)
and older. See page 47, “Medi-Cal
I. Experimental or
Members That Still Have Optional Investigational Care
Benefits” for a description of the Experimental or Investigation care is
limitations and exceptions. a service that:
• Is not seen as safe and effective
F. Cosmetic Services by generally accepted medical
Plastic surgery or other cosmetic standards to treat a condition, or
services to change the way you • Has not been approved by the
look. This exclusion does not government to treat a condition
apply to services covered under
“Reconstructive Surgery” in the This exclusion does not apply to
“Care That SFHP Covers” section services covered under “Services
on page 43. Related to Clinical Trials” in the “Care
That SFHP Covers” section on page
44. Look in the “Help In Solving
G. Dental Care Problems” section on page 53 to learn
Services that are normally done by a about Independent Medical Review for
dentist, orthodontist, or oral surgeon, denied requests for experimental
and dental appliances. You must get or investigational services.
dental services through Denti-Cal.
This exclusion does not apply to J. Hair Loss or Growth
medically necessary covered services.
This exclusion also does not apply to Treatment
certain services needed to get your Services to make hair grow or
jaw ready for radiation treatment, for hair loss are not covered.
as long as a SFHP provider gives
you a referral to a dentist. You may K. Infertility Services and
contact the Denti-Cal Beneficiary Conception by Artificial Means
Telephone Service Center at (800)
322-6384 directly for more information Services that help someone get
about covered dental care. Effective pregnant are not covered.
July 1, 2009, adults, age twenty one
(21) and older will only have limited L. Lab Services
emergency dental care through Denti- Lab services (called “serum
Cal, with some exceptions. Dental alphafetoprotein testing”) that you get
coverage is a limited benefit for certain through a State program for pregnant
members only. See page 47, “Medi- women. These services are paid for by
Cal Members That Still Have Optional DHCS (Department of Health Care
Benefits” for a description of the Services). SFHP will coordinate
limitations and exceptions. with DHCS for appropriate billing.
6534 E 0110 48
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
M. Local Education Agency S. Sexual and Erectile
Assessment Services Dysfunction drugs
Services that you get through the Drugs used for the treatment of sexual
local education agency (LEA) are not or erectile dysfunction. If one of these
covered. LEA services include various drugs is used to treat a condition other
assessments like nutritional, vision, than sexual or erectile dysfunction and
hearing, developmental, and it is approved by the Food and Drug
psychosocial status. Administration (FDA), then you
must get these drugs through
N. Personal Care Services regular Medi-Cal.
Services that are not medically
necessary, such as help with activities T. Sexual Reassignment Surgery
of daily living. Or, services that can
be done by people who do not need SFHP covers the change of anatomical
a medical license or do not have to sex only, which is the surgical
be supervised by a nurse. conversion of the sexual organs.
This exclusion does not apply to SFHP does not cover reassignment
services covered under “Skilled surgery, or related surgical procedures
Nursing Facility Care” section on page such as facial feminization and/or
44 or “Hospice Care” in the “Care That breast enhancement/reduction. These
SFHP Covers” section on page 38. procedures are considered cosmetic
and therefore are not a benefit under
O. Prayer Healing the Medi-Cal program. Surrogacy
Services for anyone related to the
You must get these services through
member in a surrogacy arrangement,
regular Medi-Cal. They are not covered
except for services covered in this
through SFHP.
booklet that are provided to a member
who is a surrogate. A surrogacy
P. Reversal of Sterilization arrangement is when a woman
Services to reverse voluntary surgical (the “surrogate”) agrees to become
birth control (called “tubal ligation” for pregnant and give the baby to
women and “vasectomy” for men) are someone else to raise.
not covered.
U. Targeted Case
Q. Routine Foot Care Services Management Services
(Podiatry) Services that you get through the
Podiatry is the diagnosis and treatment targeted case management program
of disorders of the foot, ankle, and are not covered e.g. California
lower leg. Foot care services that are Children’s Services (CCS).
not medically necessary are not
covered. SFHP will cover podiatry V. Travel and Lodging Costs
(foot care services) when there is a
Travel and lodging costs related
medical need.
to covered services. This exclusion
does not apply if your medical group
R. Services Not Available in authorizes care from a non-SFHP
San Francisco provider and we OK (approve) the
Services not generally provided in costs in advance. This exclusion also
San Francisco. This exclusion does not does not apply to services covered
apply if you are authorized outside of under “Medical Transportation” in the
San Francisco for care or you receive “Care That SFHP Covers” section
emergency services while outside of on page 39.
San Francisco.
6534 E 0110 49
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
W. Tuberculosis party. If DHCS does not recover
these costs, we may do so.
Some TB services including directly
observed therapy are available through DHCS Has The Right to Recover and
the San Francisco Department of can ask a third party for money related
Public Health.Call them at (415) 863- to services you get from us if:
9892.
• You are hurt on the job
(“workers compensation”)
X. Waiver Programs
• You are sick or hurt due to someone
Services you get through certain waiver else, such as a car accident
programs, such as: (“Third Party tort liability”)
• In-Home Medical Care • There is money owed through your
Waiver Program; estate (estate recovery)
• Skilled Nursing Facility When DHCS has the right to recover
Waiver Program; due to a third party’s action:
• AIDS and AIDS Related • We will give you any medically
Conditions Waiver Program, and necessary services at the time
• Multipurpose Senior Services services are needed
Waiver Program. • We will let DHCS know about
To learn more, look in the “Summary the third party’s action if we know
of Benefits” section on page 27. about it
• We will ask the third party to pay
Y. Limitations us back for the services provided
Coordination of Benefits (COB) • You will need to help us get the
If you have other health care coverage, necessary information from the third
we will coordinate the coverage you party so that we can get paid back
get under this Plan with your other Keep in mind:
coverage. We will use the COB rules of
• If the third party pays you money,
the DMHC (the Department of
you must pay DHCS for services
Managed Health Care):
that we paid for or gave to you
• The COB rules decide which
• The amount you owe DHCS will
coverage pays first
never be more than the amount
• Medi-Cal always pays last you get from the third party
• We will only pay up to an amount
that, when added together with the SFHP will not pay for the following:
payment from the other coverage,
would be equal to the 1. Services Covered by an Employer
Medi-Cal benefit
We will not pay for services that
Keep in mind: your employer must give to you by
• You must let us know if you law.
have other coverage If we give you any of these services,
we may ask your employer to pay
• You must fill out any forms we us back for the cost of these
need to coordinate your benefits services.
Z. Reductions 2. Services Covered by Government
Agencies
If the cost of services is paid by
another source (a “third party”), DHCS We will not pay for services that a
(the Department of Health Care government agency must give to
Services) may have a right to you by law. If we give you any of
get the money back from the third these services, we may ask the
6534 E 0110 50
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
agency to pay us back for the as possible, but at least within seven
cost of these services. days after the first day you become
a member SFHP will mail you
3. Services Covered by Medicare
membership materials. You should
If you are eligible for Medicare, get a SFHP member ID card, an SFHP
you must let us know. The Medicare Medi-Cal Provider Directory that lists
Program may have to pay for certain all the SFHP providers, hospitals,
services you get from us. Medi-Cal clinics, and pharmacies and this
always pays last. Handbook. If you need another copy
of any of these materials, just call
4. Services Covered by the Member Services at (415) 547-7800
Veterans’ Administration (local) or (800) 288-5555.
We will not pay for services
needed due to military service that C. When Your Coverage Ends
the Veterans’ Administration (“VA”) If the Department of Health Care
must give you by law. If we give you Services disenrolls you from SFHP, your
any of these services, we may ask coverage will end at midnight on the first
the VA to pay us back for the cost day of the second month following
of these services. receipt by DHCS of all documentation
5. Immigration Medical Exams necessary to process and determine
your disenrollment. Except for
You are responsible for paying all disenrollments regarding Major Organ
costs of the medical exam, including Transplants, for which disenrollments
the cost of any follow-up tests or shall be effective the beginning of the
treatment that may be required. month in which the transplant is
Payments are made directly to the approved.
civil surgeon or other health care
facility. A civil surgeon is a board 1. Health Care Options
certified medical doctor or doctor of Health Care Options (HCO) is the
osteopathy who meets the organization that processes your
requirements to be designated as application into SFHP and your
such by the U.S. Citizenship and request for disenrollment from
Immigration Services Department. SFHP. If you would like help with
a disenrollment request, you can
call HCO at (800) 430-4263.
7. Termination of Coverage 2. Expedited Disenrollment
In certain circumstances, HCO
A. If You Get Cut-Off will process your request for
From Medi-Cal disenrollment within 48 hours. If you
are an American Indian, you have the
Medi-Cal decides when you join SFHP, right to disenroll from our Plan at any
when you leave SFHP, and when you time, without cause. If you need
are “on hold.” SFHP has nothing to services that you cannot get from
do with these decisions. Please call SFHP, if you are receiving services
the San Francisco Medi-Cal Office at through the Foster Care Program, or
(415) 558-1853, if you have questions if you have been incorrectly enrolled
about your Medi-Cal eligibility. in SFHP, call Health Care Options to
request an expedited disenrollment.
B. Start of Coverage Other circumstances for
You become a member of SFHP disenrollment include major organ
at 12:01am on the first day of the transplants and members already
month in which your name is added enrolled in another Medi-Cal,
to the approved list of members Medicare or commercial managed
sent to SFHP by Medi-Cal. As soon care plan.
6534 E 0110 51
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
D. Coverage for Your New Baby form. SFHP will cover the child until
Medi-Cal tells us the child is on
If you have a baby while you are a
regular Medi-Cal.
member of SFHP, your baby will be
covered by SFHP under your name
during the month of the baby’s birth G. How to Leave SFHP
and the following month. Be sure to If you did not choose a health
apply for Medi-Cal for your baby plan when you enrolled, you were
as soon as possible after birth to automatically assigned to SFHP.
make sure your baby gets all the If you want to change health plans,
health care needs. you can do so at any time for any
reason by calling Health Care Options
You may enroll your baby in SFHP.
at (800) 430-4263. You can also call us
If you do not enroll your baby in SFHP,
and we will assist you. You may have
your baby will not be covered by SFHP
to join another managed care plan.
after the end of the month following the
baby’s birth. For example, if your baby is If you are thinking about leaving
born on January 15, your baby would be SFHP, we would like to talk to you.
covered for January and February only. SFHP wants you to have the best care
and service possible. If you are unhappy
E. Adopted Children with us, we want to know as soon as
possible. We want to help you solve any
If you adopt a child while you are a
problems. Please call Member Services
member of SFHP, your adopted child
at (415) 547-7800 (local) or
will be covered by SFHP under your
name during the month you adopted the (800) 288-5555.
child and the following month. Be sure
to apply for Medi-Cal for your adopted H. Disenrollment
child as soon as possible after adoption In some cases, we may no longer
to make sure your baby gets complete be able to serve you and you will
health care. have to leave SFHP. This process
You may enroll your adopted child is called disenrollment.
in SFHP. If you do not enroll your Some of the reasons for
adopted child in SFHP, your adopted disenrollment are:
child will not be covered by SFHP
after the end of the month following • You move out or do not work in
the adoption. For example, if you San Francisco which is the only
adopt your child on January 15, area we serve
your adopted child will be covered • You lose your Medi-Cal eligibility
for January and February. (this decision is made by Medi-Cal,
not by SFHP)
F. Foster Children • If you are accepted as a transplant
A child in a foster care or adoption candidate, the state will disenroll you
assistance program or a child who only if the transplant center’s
is eligible for placement out of the evaluation has concurred that you
home can be disenrolled from SFHP are a candidate for major organ
and enrolled in regular Medi-Cal. transplant, and the major organ
Regular Medi-Cal is often better for a transplant is authorized by either the
child in this situation since the child can DHCS Medi-Cal field office (for
get care in more than one county. If you adults) or the California Children’s
think this would be better for the child, Services Program (CSS) (for
contact the child’s caseworker or SFHP children).
to assist you in making this change. • You need to be in a nursing home for
According to Medi-Cal, requests will the month of admission plus the next
be processed within 48 hours after month except in cases of hospice
Medi-Cal receives your disenrollment care which are not long term care
6534 E 0110 52
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
regardless of the length of stay in a I. Losing Your Medi-Cal
nursing facility. Timeframes do not Eligibility
apply for members who have elected
hospice that are in a nursing home. Transitional Medi-Cal (TMC) may
(covered by regular Medi-Cal) be available to you if you lose cash
aid or Medi-Cal eligibility because you
• You commit fraud or deception in are earning more money. If you lose
the use of the services or facilities eligibility for Medi-Cal, you should
of SFHP immediately ask your county
• You let someone else use your caseworker, whether you may
SFHP member ID card continue your TMC. TMC is usually
• You present a false prescription called “Medi-Cal for working people.”
TMC is only available to primary
• Your behavior is such that it wage earners or caretaker relatives
threatens the safety of SFHP (as defined by Medi-Cal) and their
employees, providers, members
children whose coverage is ended
or other patients or your repeated
because of increased earnings from
behavior substantially impairs employment, marriage, or a spouse
SFHP’s ability to furnish or arrange
returning to the home. Parents,
services for membersor other
caretaker relatives, and children
members or a provider’s ability to who meet the requirements for
provide services to other patients
TMC may continue no-cost Medi-Cal
coverage for up to 12 months of TMC
A disenrollment request is processed for a total of 24 months.
by the Department of Health Care
Services (DHCS). They may take up to J. Help With Legal Matters
45 days to decide. During this time, you
Bay Area Legal Aid (BALA) is a
will continue to be covered by SFHP.
non-profit law office which helps low-
Once your disenrollment is complete,
income people living in San Francisco
you will no longer be able to get care
including helping people get health care
from SFHP, but in most cases you will
such as Medi-Cal, the Healthy Families
still be covered by regular Medi-Cal or
Program, and In-Home Supportive
by another managed care plan.
Services. BALA can also help with
Complaints Regarding Disenrollment other legal issues such as housing,
domestic violence, and public benefits
If you think that you have been (CAL WORKS, SSI, Food Stamps,
disenrolled from SFHP because of General Assistance/PAES and
an illness you have or because you unemployment insurance). BALA is
asked for medical services, you can open Monday through Friday, 9:00am
complain to the Department of to 5:00pm. Call (415) 982-1300 for
Managed Health Care by calling them more information.
at (888) 466-2219. You can also call
the Office of the Ombudsperson at 8. Help In Solving Problems
the Department of Health Care
Services at (888) 452-8609. The Office
of the Ombudsman (OMB) serves as a A. What Do I Do If I Have a
resource for you to solve issues
related to health care access. The Office
Complaint? Can I Just
of the Ombudsman is also responsible Call SFHP?
for coordinating and processing State If you are having a problem with your
Fair Hearing requests. Although SFHP provider, we suggest you talk to your
Member Services department is the first provider first to see if you can get the
and main resource to get your questions problem solved quickly. If this does
answered and to solve disputes, the not work, or if you do not want to talk
Office of the Ombudsman is available to your provider, call SFHP. We will
to you at any time.
6534 E 0110 53
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
do our best to help you fix the problem. file a grievance with SFHP by calling
You must file a grievance with San us at (415) 547-7800 (local) or
Francisco Health Plan within one (800) 288-5555. The TDD number is
hundred and eighty (180) days from the (415) 547-7830 (local) or (888) 883-
date the incident or action occurred 7347 (toll free) If you want to file
which caused you to be dissatisfied. If a grievance in writing, send it to:
you are dissatisfied with a Notice of
Action letter from San Francisco Health San Francisco Health Plan
Plan telling you that a medical service Grievance Coordinator
has been denied, deferred or modified, 201 Third Street, 7th Floor
you have ninety (90) days from the date San Francisco, CA 94103
of the Notice of Action to file an appeal. Also, grievance forms are available
(see “What If I Don’t Like How SFHP from SFHP, on the SFHP Web Site
Has Answered My Complaint?” On (www.sfhp.org) or at your
page 54) primary care provider’s office.
Please note: SFHP cannot do anything
about your Medi-Cal eligibility or the B. How Long Will It Take You
benefits you are entitled to under to Look Into and Answer
Medi-Cal. Medi-Cal eligibility and
Medi-Cal benefits are determined by
My Complaint?
Medi-Cal, not by SFHP. If you have any In most cases, within five days after
questions about your Medi-Cal eligibility, you file the grievance, we will mail you a
please call Medi-Cal at (415) 558-1853. letter letting you know we received your
grievance. SFHP will tell you how we
You can ask for a State Fair Hearing have handled it as soon as we can, but
if you want to complain about how always within 30 days from when we got
Medi-Cal has handled your eligibility your grievance.
or benefits. A State Fair Hearing is
an administrative procedure by which
C. What If I Don’t Like How SFHP
members with a grievance can present
their cases directly to the State of Has Answered My Complaint?
California for resolution. You can also If you do not accept SFHP’s solution,
file for a State Fair Hearing directly by or if we have taken longer than 30 days
calling Department of Social Services’ to resolve your grievance from the day
Public Inquiry and Response Unit at you first filed, you can go directly to the
(800) 952-5253, or by mail to the Department of Managed Health Care
San Francisco County Department of or Department of Health Care Services
Social Services (CDSS) at 1390 Market for help. The California Department of
Street, Room 325, Fox Plaza Building, Managed Health Careis responsible for
San Francisco, California. You can also regulating health care service plans. If
call CDSS if you need legal assistance you have a grievance against your
at (415) 557-0180 or fax to health plan, you should first telephone
(415) 557-0182. SFHP at (415) 547-7800 or (800) 288-
5555 and use The Plan’s grievance
Any kind of complaint you make about
process before contacting DMHC. Using
SFHP or an SFHP provider is called
this grievance procedure does not
filing a grievance with SFHP. Filing a
change any legal rights or remedies that
grievance is your right. Neither SFHP
may be available to you. If you need
nor your provider will discriminate
help with a grievance involving an
against you if you file a grievance.
emergency, a grievance that has not
SFHP also will not disenroll you
been satisfactorily resolved by SFHP, or
because you file a grievance.
a grievance that has remained
You can file a grievance just by talking unresolved for more than 30 days, you
to us, or you can do it in writing and may call DMHC for assistance. You may
SFHP will provide assistance. You can also be eligible for an Independent
6534 E 0110 54
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
Medical Review (IMR). If you are eligible D. Are There Any Rules You Have
for IMR, the IMR process will provide an to Follow When You Look Into
impartial review of medical decisions
made by a health plan related to the My Complaint?
medical necessity of a proposed service SFHP has to follow very specific rules
or treatment, coverage decisions for when we deal with grievances. If you
treatments that are experimental want to know what those rules are,
or investigational in nature and call us and we will send you a copy.
payment disputes for emergency
or urgent medical services. DMHC E. What If I Need You to Decide
also has a toll-free telephone number,
In Less Than 30 days?
(888) HMO-2219 and a TDD line
(877) 688-9891 for the hearing and You can ask that SFHP review
speech impaired. DMHC’s Internet Web your grievance or appeal within
Site http://www.hmohelp.ca.gov 72 hours when your request for an
has complaint forms, IMR application authorization (to see another provider
forms, and instructions online. or for a specific medical procedure) is
denied, and a delay in your medical
If you receive a Notice of Action letter treatment could possibly harm your
from San Francisco Health Plan, you health. This is called an expedited
have three options. (A Notice of Action medical review. SFHP will give you
letter is a formal letter telling you that a an expedited medical review if a delay
medical service has been denied, in your medical care would pose an
deferred, or modified). imminent and serious threat to your
health including, but not limited to, loss
• You have ninety (90) days from the
of life or limb, major bodily function or
date on the Notice of Action to file
severe pain. To file an expedited
an appeal of the Notice of Action
medical review, call SFHP at
with San Francisco Health Plan
(415) 547-7800 or (800) 288-5555
• You may request a State Hearing and tell us that you want an expedited
regarding the Notice of Action from medical review. We will help you
the Department of Social Services through the process and we will also
(DSS) within ninety (90) days. provide you with information on how
you can also immediately contact the
• You may request an Independent Department of Managed Health Care for
Medical Review (IMR) regarding the review. You do not have to participate in
Notice of Action from the SFHP’s grievance process for 30 days
Department of Managed Health before you go to the Department of
Care (DMHC) within one hundred Managed Health Care for an expedited
and eighty (180) days. medical review. If SFHP does not
You may file an appeal with San resolve an expedited issue in 72 hours
Francisco Health Plan regarding a or its resolution is not favorable, you
Notice of Action and request a State may file for an expedited State Fair
Hearing regarding that Notice of Action Hearing. You may skip SFHP’s
at the same time. However, an IMR grievance process and also apply
may not be requested if a State Hearing for an expedited State Fair Hearing.
has already been requested for that You may do so at the same time you
Notice of Action. are using SFHP’s grievance process.
SFHP or your provider will provide
You can also file a grievance that is not records supporting the need for an
about a Notice of Action. You must file expedited hearing. SFHP responds
a grievance within one hundred eighty within two business days to requests
(180) days from the date the incident or for records pertinent to the expedited
action occurred which caused you to be hearing and assigns a representative
dissatisfied. to participate
6534 E 0110 55
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
F. Do I Have to Help You with denied, changed, or delayed your
My Complaint? health care services or a request for
services that SFHP has described as
In order for SFHP to consider your being experimental or investigational
grievance as quickly as possible, you in nature (see page 48 for more
may be asked to provide information information on the IMR process
or to permit the release of medical for experimental or investigational
records. SFHP asks that you respond services). You may apply for IMR
to these requests as quickly as possible. within six months of any of the
qualifying events described below. An
G. Do I Have to Complain Only IMR may not be requested if a State
to SFHP? Can I Complain Hearing has already been requested for
that Notice of Action.Your decision not
Anywhere Else?
to participate in the IMR process may
If you have a complaint, you can also cause you to forfeit any lawful right to
contact the Office of the Patient pursue legal action against SFHP
Advocate at any time before, during or regarding the health care services at
after the grievance or appeal process. issue.
You may contact them at
(800) 743-8525. You can also request The IMR process is in addition to any
a Medi-Cal State Fair Hearing. You can other procedures or remedies that are
do this instead of filing a grievance with available, such as filing a grievance or
SFHP, or at the same time. A State Fair an appeal of a grievance. The IMR
Hearing is a process by which you can process is free. You have the right to
complain directly to the State of provide any information you have to
California and have someone judge support your request for an IMR. SFHP
your case. You can make this request or your medical group must provide you
for a State Fair Hearing by telephone with an IMR application form along with
at (800) 743-8525 or by mail to the any grievance disposition letter
San Francisco County Department of that denies, modifies, or delays
Social Services (CDSS). You can also health care services.
call CDSS if you need legal assistance. If you submit an IMR application
The Medi-Cal Managed Care Office of to the DMHC it will be reviewed
the Ombudsman helps solve problems to confirm that:
from a neutral standpoint to ensure that
you receive all medically necessary • Your physician has recommended
covered services for which SFHP a health care service as medically
is contractually responsible. The necessary, or
Ombudsman does not automatically • You have received urgent care
take sides in a complaint. It considers or emergency services that a
all sides in an impartial and fair way. provider determined was medically
Call (888) 452-8609 or (800) 430-7077 necessary, or
(TDD) for more information. You may
• You have been seen by a physician
also call SFHP for more information
for the diagnosis or treatment of the
about the State Fair Hearing process
medical condition for which you seek
or to request forms.
an IMR;
• The disputed health care service has
H. Can I Get Someone Besides
been denied, changed, or delayed by
SFHP to Look Into a Denial of SFHP or your medical group, based
Medical Services? in whole or in part
You may ask for an independent on a decision that the health care
medical review (IMR) from the service is not medically
Department of Managed Health Care necessary; and
(DMHC) if you believe that SFHP or • You have filed a grievance with
your medical group has improperly SFHP or your medical group and the
6534 E 0110 56
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
disputed decision is upheld or the The IMR process described on page 56
grievance remains unresolved after is also available if SFHP denies your
30 days. If your grievance requires request for health care services
expedited review you may bring it because we have stated that the
immediately to the DMHC’s attention. services are experimental or
The DMHC may waive the investigational in nature. This applies
requirement that you follow SFHP’s for denials of services that include
grievance process in extraordinary drugs, devices, procedures or other
and compelling cases. therapies recommended by your
physician. If SFHP denies such a
request, we will notify you in writing of
If your case is eligible for IMR,
the opportunity to request an IMR with
the dispute will be sent to a
the DMHC within five business days
medical specialist who will make an
of the decision to deny coverage.
independent determination of whether
You do not have to participate in
or not the care is medically necessary.
SFHP’s grievance process before
You will receive a copy of the
asking the DMHC for an IMR. If your
assessment made in your case.
provider decides that the proposed
If the IMR determines the service is
experimental or investigational services
medically necessary, SFHP or your
should be delivered promptly or they
medical group will provide the health
won’t be as effective, the IMR panel will
care services.
provide you with a decision within seven
For non-urgent cases, the IMR days of the request for an expedited
organization designated by the DMHC review. You can contact the DMHC
must provide its determination within 30 as described above on page 56
days of receipt of your application and and for more information on how
supporting documents. For urgent cases to request an IMR for experimental
involving imminent and serious threat to or investigational services.
your health, including, but not limited to,
serious pain, the potential loss of life, 9. Your Rights and
limb or major bodily function, or the
immediate and serious deterioration of Responsibilities
your health, the IMR organization must
provide its determination within three
business days. A. Your Rights
For more information regarding As a SFHP Medi-Cal member,
the IMR process, or to request an you have the right to:
application for an IMR, please call
• Be treated respectfully no matter
SFHP at (415) 547-7800 (local) or
what your gender, culture,
(800) 288-5555 call the Department language, appearance, sexual
of Managed Health Care at orientation, race, disability and
(888) HMO-2219 or a TDD line transportation ability is, giving due
at (877) 688-9891 or go to the consideration to your right to privacy
Department’s Web Site at and the need to maintain
http://www.hmohelp.ca.gov for confidentiality of your medical
complaint forms, IMR application information.
forms and instructions online.
• Receive information about all
health services available to you,
I. What Do I Do If I Have Been including a clear explanation of
Denied a Request for Services how to get them.
That SFHP Describes As • Select a primary care provider to
Experimental or Investigational provide or arrange for all the care
in Nature you need.
6534 E 0110 57
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
• Receive good and appropriate guardian about certain issues. If this
medical care including preventive happens, the information will be
health services and health discussed fully with you as well.
education • Have confidential health records,
• Take part actively in decisions except when disclosure is required
about your medical care. To the by law or permitted in writing by you.
extent permitted by law, you also With adequate notice, you have the
have the right to refuse or right to review your medical records
discontinue treatment. with your primary care provider.
• Know and understand your medical • Know about any transfer to another
condition, treatment plan, expected hospital, including information as to
outcome, and the effects these have why the transfer is necessary and
on your daily living. any alternatives available
• Receive linguistics services and • Get a referral from your primary
information documents translated care provider for a second opinion.
into threshold languages • Be fully informed about SFHP’s
• Receive interpreter services, appeals procedure and understand
including sign language interpreters, how to use it without fear of
at no cost to you. interruption of health care and
at no charge. Receive oral present your appeal in person.
interpretation services in • Be free from any form of restraint
your language. or seclusion used as a means of
• Formulate advance directives. coercion, discipline, convenience,
• Have access to family planning or retaliation.
services, Federally Qualified Health • Take part in establishing public
Centers, Indian Health Services policy of SFHP, by attending and/or
Facilities, sexually transmitted joining the SFHP Member Advisory
disease services, and Emergency Committee and
Services outside of the SFHP attending any SFHP Governing
network pursuant to the federal law. Board meeting.
• File a complaint or grievance if • Freedom to exercise these
your cultural and linguistic needs rights without adversely
are not met. affecting how you are treated
• Request a State Medi-Cal fair by San Francisco Health Plan,
hearing including information on providers, or the State.
the circumstances under which an • To disenroll upon request.
expedited fair hearing is possible. B. Your Responsibilities
• Access minor consent services. As an SFHP Medi-Cal member,
• Receive written Member informing you have the responsibility to:
materials in alternative formats,
including Braille, large size print, • Carefully read all SFHP materials
and audio format upon request. immediately after you are enrolled
so you understand how to use your
• Receive information on available SFHP benefits.
treatment options and alternatives,
presented in a manner appropriate • Ask questions when needed.
to your condition and ability • Follow the provisions of your SFHP
to understand. membership as explained in this
• Have the meaning and limits of Handbook
confidentiality explained to you. You • Be responsible for your health.
understand that if you are a minor, • Follow the treatment plans your
your provider or other staff may provider develops for you and
need to talk with your parents or
6534 E 0110 58
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
consider and accept the possible ID, and your Medi-Cal ID card with
consequences if you refuse to you when you come in for care.
follow with the treatment plans • Telling us if you receive care
or recommendations. at a non-SFHP contracted
• Ask questions about your medical facility/provider.
condition and make certain that you • If you require an interpreter, you
understand the explanations and should request an interpreter in
instructions you are give advance prior to your appointment.
• Make and keep medical
appointments and let your provider
know ahead of time when you must 10. Other Facts About
cancel.
SFHP
• Communicate openly with your
physician so you can develop a
strong partnership based on trust
and cooperation. A. Arbitration of Disputes
• Offer suggestions to improve SFHP. If there is any dispute or disagreement
• Help SFHP maintain accurate between a member and SFHP (other
and current medical records by than a claim of medical malpractice) that
providing information promptly about exceeds the jurisdiction of Small Claims
changes in address, family status, Court, the member and SFHP shall
and other health plan coverage. settle the dispute by final and binding
arbitration. The arbitration shall take
• Notify SFHP as soon as possible place in San Francisco, California.
if you are billed inappropriately A member shall request arbitration by
or if you have any complaints. written notice to SFHP within the same
• Treat all SFHP staff and health time limits provided by California law
professionals respectfully and if a member were to file a civil lawsuit
courteously. regarding the same matter.
• As required by Medi-Cal Program, If the total amount of damages claimed
pay any premiums, co-payments by the member is $200,000 or less, the
and charges for non-covered dispute shall be resolved by a single
services on time. arbitrator selected by the parties
• You may refuse, for personal within 30 days of the date SFHP
reasons, to accept procedures or receives your request for arbitration,
treatment recommended by your or if the parties can not agree on a
medical group or primary care single arbitrator, then selected by the
provider. If you refuse to follow method provided in Section 1281.6 of
a recommended treatment or the California Code of Civil Procedure.
procedure, your medical group or Such arbitrator shall have no jurisdiction
primary care provider will let you to award more than $200,000.
know if he or she believes that there
If the amount of damages claimed
is no acceptable alternative
by the member exceeds $200,000,
treatment. You may seek a second
then within 30 calendar days of the
opinion as provided in
date SFHP receives your request for
this Handbook. If you still refuse the
arbitration, you and SFHP shall attempt
recommended treatment or
to agree upon a single arbitrator. If the
procedure, then SFHP has no
parties can not agree upon a single
further responsibility to provide any
arbitrator within this 15 day period,
alternative treatment or procedure
then one arbitrator will be named by
that you seek.
SFHP and one arbitrator shall be named
• Using your ID cards properly. by you, and a third neutral arbitrator will
Bring your SFHP ID card, a photo be named by the arbitrators within 30
6534 E 0110 59
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
calendar days of your request for have any such dispute decided in a
arbitration. If the two arbitrators cannot court of law before a jury, and instead
agree on a neutral arbitrator, or if for any are accepting the use of arbitration.
other reason a neutral arbitrator is not This requirement does not waive a
selected within 30 days of your request member’s right to a jury trial for claims
for arbitration, the method set forth in of medical malpractice.
Section 1281.6 of the California Code of
Civil Procedure may be used by either B. Public Policy Participation
party to select the neutral arbitrator. SFHP is a publicly sponsored health
plan. Meetings of its Governing Board
Except as otherwise described in
are open to the public. The Plan has
this section, “Arbitration of Disputes,”
established a Member Advisory
the arbitration provisions set forth
Committee (MAC) to advise its
in Title 11 of Part 3 of the California
Governing Board on policy decisions.
Code of Civil Procedure, including
Two members of this committee also
Section 1283.05 thereof permitting
are members of the Governing Board
expanded discovery proceedings,
and one is a member of the SFHP
shall be applicable to all disputes or
Quality Improvement Committee.
controversies which are arbitrated
In conformance with Health and Safety
between you and SFHP.
Code, Section 1369, SFHP encourages
The decision and award of the arbitrator its members to participate in the
shall be rendered as soon as possible establishment of its policies related
after the hearing and submission to acts performed by SFHP (and its
of the matter by the parties, but not employees and staff) to assure the
longer than 30 calendar days thereafter. comfort, dignity and convenience of
The decision shall be in writing, shall patients who rely on the SFHP’s
indicate the prevailing party, the facilities to provide health care
amount of any award, other relevant services to them, their families and
terms of any award, and the reasons the public. The names of the members
for any award rendered. Judgment of the Member Advisory Committee
upon the award rendered by the and of the Governing Board may be
arbitrators may be entered by either obtained by calling Member Services
party in any court having jurisdiction at (415) 547-7800 (local) or
thereof. The arbitrators shall have no (800) 288-5555. If the member is
authority to award punitive or exemplary interested in participation in the future,
damages. Each party shall be solely please contact Member Services.
responsible for his/her/its own attorneys’
fees and costs. C. Non-Assignability
Benefits of SFHP are not assignable
The costs of the neutral arbitrator shall
without the written consent of SFHP.
be shared equally by you and SFHP,
provided that in the case of extreme D. Independent Contractors
hardship, SFHP shall be responsible
SFHP providers are neither agents
for all costs of the neutral arbitrator.
nor employees of SFHP but are
An application for you to request that
independent contractors. Providers
SFHP be responsible for all costs for
may be independent contractors to
of the neutral arbitrator may be obtained
the medical group with which SFHP
from Member Services. If SFHP does
contracts. In no instance shall SFHP
not agree to be responsible for all costs
be liable for negligence or wrongful
of the neutral arbitrator when an
acts or omissions of any person
application for such relief is made by
who provides services to members,
the member, such determination shall
including any physician, hospital or
be made by the neutral arbitrator.
other provider or their employees.
It is understood that the parties are
giving up their constitutional right to
6534 E 0110 60
SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
E. Confidentiality of of SFHP. SFHP shall exercise this
Medical Information authority for the benefit of all persons
entitled to receive benefits under the
THIS NOTICE DESCRIBES HOW contract and Evidence of Coverage.
MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND G. Governing Law
DISCLOSED. THIS NOTICE ALSO SFHP’s Medi-Cal Program coverage
DESCRIBES HOW YOU CAN GET is subject to the requirements of the
ACCESS TO THIS INFORMATION. California Knox-Keene Act, Chapter 2.2
PLEASE REVIEW IT CAREFULLY. of Division 2 of the California Health
San Francisco Health Plan (SFHP) and Safety Code, and the regulations
is required by law to safeguard privacy set forth Division 3 of Title 22 of the
of your health information. We are also California Administrative Code. Any
required to let you know of our privacy provision required to be in this benefit
practices regarding your protected program by either the Knox-Keene Act
health information (PHI). or the regulations shall be binding
on SFHP, even if it is not included
SFHP may use your health information in this Evidence of Coverage or the
to pay for your health care, to allow health plan contract.
your provider to provide treatment
to you or for other SFHP operations. H. Natural Disasters,
You have the right to request a Interruptions, Limitations
complete description of our policies
In the event of a natural disaster
describing how we use your information.
or other unforeseeable circumstances,
You also have the right to see your
which are beyond SFHP’s reasonable
medical record or to request a restriction
control, it may be impossible for
on how we use or disclose your health
SFHP to provide services to members.
information, except for purposes of
Examples of reasons beyond SFHP’s
treatment, payment or SFHP operations.
control include natural disaster, war,
Contact SFHP Member Services and
riot, labor dispute involving a SFHP
ask for the Plan’s Compliance Officer to
or other health professional, civil
file a complaint about the SFHP’s use of
insurrection, or epidemic. In the event
your health information, or to request
of a natural disaster, the member should
a copy of our privacy policies.
proceed to the nearest emergency room
SFHP and its providers are prohibited if they believe they have an emergency
from intentionally sharing, selling, using medical condition. SFHP will reimburse
or disclosing any medical information the member for the services received.
unrelated to a patient's health care
without the patient's permission, 11. Organ Donation
unless the disclosure is legally
compelled. Every SFHP physician
handling medical records must Donating organs and tissues provides many
preserve patient confidentiality. societal benefits. Organ and tissue donation
Note: A statement describing SFHP's allows recipients of transplants to go on
policies and procedures for preserving to lead fuller and more meaningful lives.
the confidentiality of medical records is Currently, the need for organ transplants
available and will be furnished to you far exceeds availability. If you are interested
upon request. in organ donation, please speak with your
physician. The Department of Health
F. Benefit Program Participation and Human Services’ Internet website
SFHP shall have the power and (http://www.organdonor.gov) has
discretionary authority to construe additional information on donating your
and interpret the provisions of the organs and tissues. You can also call
health plan contract and the Evidence of (800) 355-SHARE (7427) to get a donor
Coverage and to determine the benefits
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card and to obtain more information about (“immunizations”) for children up
organ donation. to age 21.
Chemical Dependency Services: Certain
12. Words You medically necessary services for alcohol or
Should Know drug addiction. Look in the “Care That SFHP
Covers” section to learn more.
Child: A beneficiary under the age of
Some words that are italicized in twenty one (21)
this booklet have special meaning.
This section tells you the meaning Chronic: A health condition that is long-term
of these words. If you have questions, and ongoing.
call us at (415) 547-7800 (local) or Clinical Trial: A study to find out if a
(800) 288-5555. Member Services new treatment is effective. Look in the
can answer your questions five days “Care That SFHP Covers” section on
a week, from 8:00am to 6:00pm in page 44 to learn more.
any language you speak.
Complaint: A complaint is also called a
Acute: A health condition that is sudden grievance or an appeal. Examples of a
and lasts a limited duration. complaint can be when: you can’t get a
Adult: A beneficiary age twenty one (21) service, treatment, or medicine you need;
and over your plan denies a service and says it is not
medically necessary; you have to wait too
Appropriately Qualified Health Care long for an appointment; you received poor
Professional: A provider who is acting care or were treated rudely; your plan does
within his or her scope of practice and who not pay you back for emergency or urgent
has the clinical background related to the care that you had to pay for; you get a bill
illness or condition. that you believe you should not have to pay
Arbitration: A way to solve problems using Co-pay: The amount you must pay when
a neutral third party. For problems that are you get covered services.
settled through Arbitration, the third party
hears both sides of the issue and makes a Covered: SFHP will pay for the services
decision that both sides must accept. Both if you follow all of the other rules in this
sides give up the right to a jury or court trial. Handbook like getting the care from an
To learn more, read “Arbitration” in the “Help SFHP provider and getting approval for
in Solving Problems” section on page 59. any specialty services or hospital care.
Authorization: Your medical group, Dental Care and Services: Are services
or sometimes SFHP, giving written OK or treatment on or to the
(authorization) for services before you teeth or gums whether or not caused by
get them. accidental injury, including any appliance
or device applied to the teeth or gums.
Benefits (Covered Services): Medically
necessary services, supplies, and drugs that DHCS (Department of Health Care
a member is entitled to receive according Services): The State office that oversees
to the terms of SFHP’s contract and the the Medi-Cal Program.
Handbook. DMHC (California Department of
CCS (California Children’s Services): A Managed Health Care): The State office
program that covers services for people up that oversees managed care health plans.
to age 21 with certain health problems. See Durable Medical Equipment: Certain
page 26 for more information medically necessary equipment that is for
CHDP (Child Health and Disability repeat use, used for a medical purpose.
Prevention Program): A program Not useful to someone who is not ill or hurt.
that covers checkups and shots Safe for use in the home. Look in the “Care
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That SFHP Covers” section on page 36 to guarantee that it will be prescribed by your
learn more. doctor for a particular condition.
Emergency Care: Includes medically Grievance: Means any expression
necessary ambulance services, an exam to of dissatisfaction made by a member
find out if an emergency medical condition in either verbal or written form and
exists. If such a condition exists, medically received by SFHP.
necessary services needed to make you
Handbook: A booklet that tells you what
clinically stable. Look in the “Emergency
services are covered. It also tells you how to
Medical Care” section on page 11 to
get services. This booklet is your Handbook.
learn more.
Health Care Options (HCO): The State
Emergency Medical Condition: A medical
office that enrolls and disenrolls members.
or psychiatric condition which is manifested
by acute symptoms of sufficient severity Health Education: Programs and classes
(including severe pain), such that a prudent that can help you protect and improve
layperson, who has an average knowledge your health. Look in the “Care That SFHP
of health and medicine, could reasonably Covers” section on page 37 to learn more.
expect the absence of immediate medical
attention to result in: Hospital Inpatient Care: Services
that you get when you are admitted to a
• Placing the health of the individual (or, Plan hospital. Look in the “Care That SFHP
in the case of a pregnant woman, the Covers” section on page 34 to learn more.
health of the woman or her unborn child)
in serious jeopardy, or Hospital Inpatient Services:
Include only those services which are
• Serious impairment to bodily medically necessary and satisfy the hospital
functions, or requirements, require the acute bed-patient
• Serious dysfunction of any bodily (overnight setting), and which could not
organ or part have been provided in a physician’s office,
Exclusion: Services that we do not cover. the outpatient department of a hospital,
or in another lesser facility without adversely
Experimental or Investigational: affecting the patient’s condition or the quality
A service that we or your medical group find: of medical care rendered. SFHP does not
Is not seen as safe and effective by cover inpatient services for medical
generally accepted medical standards to observation and evaluation, if it is medically
treat a condition, or has not been approved unnecessary.
by the government to treat a condition
• For diagnostic studies that could have
Fair Hearing: A way to solve problems been provided on an outpatient basis;
where you present your case to the State.
• For medical observation
Look in the “Solving Problems” section on
or evaluation
page 53 to learn more.
• To remove the patient from
Family Planning Services: Certain his/her customary work or home
medically necessary services that prevent environment for personal comfort;
or delay pregnancy. Look in the “Care That
SFHP Covers” section to learn more. • In a pain management center
to treat or cure chronic pain;
FDA (Food and Drug Administration): • In an eating disorder unit to
The Federal Agency that approves drugs treat eating disorders; or,
and devices for use in health care.
• For inpatient rehabilitation
Formulary: A list of brand-name and provided on an outpatient basis.
generic prescription drugs approved SFHP reserves the right to review all
for coverage and available without prior services to determine whether they are
approval from SFHP. The presence of a medically necessary.
prescription drug on the formulary does not
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Independent Medical Review: worker, or marriage, family and child
An appeal process run by the DMHC counselor, for diagnosis or treatment
(the California Department of Managed of mental or emotional disorders or the
Health Care). Look in the “Solving mental or emotional problems associated
Problems” section on page 53 to learn more. with an illness, injury,or any other condition.
Interpreter: Someone who translates what Member: A person who is on the list
is said in one language to another language. of people that Medi-Cal gives SFHP to
cover. In this Handbook, “you” or “your”
Life-threatening: Means either or means members (except in the “Arbitration
both of the following: (a) Diseases or of Disputes” section on page 59).
conditions where the likelihood of death is
high unless the course of the disease or OB/GYN: SFHP providers who specialize
condition is interrupted; (b) Diseases or in women’s health.
conditions with potentially fatal outcomes,
Occupational Therapy: Medically
where the end of point of clinical intervention
necessary services to help someone who is
is survival.
injured or disabled keep the ability to do, or
Limitation: A limit to services that get better at, activities of daily living. Look in
we cover. the “Care That SFHP Covers” section on
page 45, to learn more.
Medi-Cal: A health care program
that is paid for by State and Federal funds. Orthotic Devices: Medically necessary
See “What is the Difference Between items that support or correct a body part.
Medi-Cal and SFHP” on page 28 and Fee- Look in the “Care That SFHP Covers”
for-Service Medi-Cal (“Regular Medi-Cal”) section on page 42, to learn more.
on page 13.
Ostomy Supplies: Medically necessary
Medical Group: The group of primary care supplies that take waste out of the body.
providers and specialists who work together. Look in the “Care That SFHP Covers”
SFHP medical groups usually agree to send section on page 40, to learn more.
their members to just one hospital.
Out-of-Area Urgent Care: Medically
Medi-Cal Managed Care: A kind of necessary services you get for an
Medi-Cal where the State pays health plans unexpected illness or injury when you are
a fixed fee (called a “capitation”) for services outside of San Francisco and:
that the plan provides.
• You need the services to prevent
Medical Transportation: Transport serious worsening of your health
that is medically necessary. Look in the • You have an unexpected illness, injury,
“Care That SFHP Covers” section on or complication of an existing condition,
page 39, to learn more. including pregnancy care, for which
Medically Necessary: Services which treatment cannot be delayed until you
are reasonable and necessary to protect life, return to San Francisco
to prevent significant illness or significant • You are pregnant and need maternity
disability, or to alleviate severe pain through services necessary to prevent serious
the diagnosis, or treatment of disease, worsening of your health or your fetus’
illness or injury. For members under the health based on your reasonable belief
age of 21, medical necessity services that you have a pregnancy-related
also include EPSDT services necessary condition for which treatment cannot be
to correct defects and physical and mental delayed until you return to San
illness and conditions discovered by Francisco.
screening services. Outpatient Care: Medically necessary
Mental Health: Includes psychoanalysis, services that you get:
psychotherapy, counseling, medical • In an SFHP clinic or provider’s
management or other services most office or
commonly provided by a psychiatrist,
psychologist, licensed clinical social
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• In an SFHP hospital, when you do not Regular Medi-Cal: A kind of Medi-Cal
stay overnight in the hospital where the State pays providers a fee based
Look in the “Care That SFHP Covers” on the services they provide. This kind of
section on page 35, to learn more. Medi-Cal is also called “fee-for service.”
PCP (Primary Care Provider): Your SFHP Rehabilitation Services: Medically
doctor or nurse practitioner or certified nurse necessary services that help someone who
midwife or physician assistant. is injured or disabled keep the ability to do,
or get better at, activities of daily living.
Pharmacy Services: Medically necessary The services can include physical therapy,
drugs, supplies, and supplements. Look in speech therapy, and occupational therapy.
the “Care That SFHP Covers” section on Look in the “Care That SFHP Covers”
page 41, to learn more. section on page 45, to learn more.
Physical Therapy: Medically necessary Respiratory Therapy: Medically necessary
services that use exercises and hands on services that help with breathing. Look in the
care to help someone who is sick or hurt “Care That SFHP Covers” section on page
keep or improve function. Look in the “Care 34 and 35, to learn more.
That SFHP Covers” section on page 45,
to learn more. Routine Care: Medically necessary services
that are not urgent care or emergency care.
Post-Stabilization Care: Services you get
after the provider who is treating you finds Second Opinion: A consultation
that you are clinically stable after an with an SFHP medical group
emergency medical condition. Look in the physician other than the primary care
“Emergency Medical Care” section on page provider or referred specialist before
20, to learn more. scheduling certain services, usually
involving surgery.
Prosthetic Devices: Medically necessary
items that replace all or part of an organ or Serious Chronic Condition: A medical
limb. Look in the “Care That SFHP Covers” condition due to a disease, illness, or other
section on page 42, to learn more. medical problem or medical disorder that is
serious in nature, and that does either of
Protected Health Information: Health the following:
information that includes your name,
address, or something else that reveals • Persists without full cure or worsens
who you are. over an extended period of time.
• Requires ongoing treatment to maintain
Psychiatric Emergency Medical
remission or prevent deterioration.
Condition: a mental disorder where there
are acute symptoms of sufficient severity to Services: include the medically necessary
render either an immediate danger to benefits that are covered by SFHP when
yourself or others, or you are immediately requested and provided in accordance with
unable to provide for or use, food, shelter, or the rules set forth in this EOC.
clothing due to the mental disorder. Sensitive Services: Medically necessary
Reconstructive Surgery: Medically services for STDs (“sexually transmitted
necessary surgery to correct or repair parts diseases”), HIV/ AIDS, sexual assault, and
of the body that are not normal. Look in the to end a pregnancy (an “abortion”). Look in
“Care That SFHP Covers” section on page the “Care That SFHP Covers” section on
43, to learn more. page 43, to learn more.
Reduction: When other sources Services: Health care services
must pay for services that we cover. See or items.
Section titled “Fee-for-Service Medi-Cal SFHP (San Francisco Health Plan):
(“Regular Medi-Cal” on page 13. Your Medi-Cal managed care health plan.
Referral: The process used by an SFHP SFHP Contract: The contract between
provider to arrange for services by a SFHP and the Medi-Cal Program that
specialist or other provider.
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SAN FRANCISCO HEALTH PLAN Medi-Cal Evidence of Coverage and Disclosure Form
establishes the services, eligibility,
and other terms and conditions of coverage.
Call Member Services at (415) 547-7800
(local) or (800) 288-5555 to request a copy.
SFHP Doctor/Physician: A doctor who
agrees to give services to SFHP members.
SFHP Facility: A clinic, provider’s office,
or hospital that agrees to give services
to SFHP members.
SFHP Pharmacy: A pharmacy that agrees
to provide medications to SFHP members.
SFHP pharmacies are listed in the SFHP
Provider Directory or you can call SFHP
to find an SFHP pharmacy near you.
SFHP Provider: A hospital, SFHP provider,
or other health care provider who has
agreed to give services to SFHP members
and who belongs to your medical group.
Short-Doyle Mental Health Services:
Certain medically necessary services
for chronic and long-term mental illness.
Look in the “Care That SFHP Covers”
section on page 34, to learn more.
Skilled Nursing Facility: A facility we
contract with that provides 24 hour a day
skilled nursing care. The facility must
be licensed by DHCS (the Department of
Health Care Services)
and meet MediCal and Medicare standards.
Specialty Mental Health Services:
Certain medically necessary outpatient care
or hospital inpatient care that you get from
a mental health care specialist. Look in the
“Care That SFHP Covers” section on page
40, to learn more.
Speech Therapy: Medically necessary
services to help someone speak or swallow
better. Look in the “Care That SFHP Covers”
section on page 45, to learn more.
State: The State of California.
Urgent Care: Medically necessary services
that are needed promptly, but are not an
emergency medical condition. Look in the
“Urgent Care” section on page 12,
to learn more.
Urological Supplies: Medically necessary
supplies that capture urine outside the body.
Look in the “Care That SFHP Covers”
section on page 40, to learn more.
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Neighborhoods Covered by SFHP
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