Members in both Medicare and Medi-Cal

If you are in both Medicare and Medi Cal, San Francisco Health Plan (SFHP) pays for the care that Medi-Cal covers. Medicare is your primary insurance. That means Medicare always pays before Medi-Cal pays.
Medicare is separate from Medi-Cal and has different rules from Medi-Cal. SFHP is a Medi-Cal plan and does not provide Medicare coverage. For more information about your Medicare coverage, read the documents you received from the Medicare program or your Medicare plan.

What does SFHP/Medi-Cal cover?

The services that SFHP/Medi-Cal pays for depends on what kind of Medicare coverage you have. SFHP pays for care covered by Medi-Cal that your Medicare does not cover.

• If you have Original Medicare Part A only, your Medicare covers hospital services, but not doctor’s visits and other outpatient care. SFHP/Medi-Cal will cover outpatient care that you get from in-network SFHP providers. You may need pre-approval (prior authorization) from SFHP to see an out-of-network doctor.
• If you have Original Medicare Part B only, your Medicare covers outpatient care, but not hospital services. You may need pre-approval from SFHP to get non-emergency care at an out-of-network hospital.
• If you have Original Medicare Parts A and B or you are enrolled in a Part C Medicare Advantage Plan, SFHP/Medi-Cal will cover care covered by Medi-Cal that your Medicare does not cover.

More information about your Medi-Cal benefits is available in your SFHP Member Handbook.

What providers can I see?

• If your SFHP member ID card lists “SFHP Direct Network” as your medical group, you are in a new medical network called SFHP Direct Network (SDN). You do not have to choose a primary care provider. This means that you can get care from any in-network SFHP provider in any medical group. For a list of Medi-Cal providers available to you, search the SFHP Provider Directory.
• If your SFHP member ID card lists a medical group that is not SFHP Direct Network, you are assigned a primary care provider who manages your care and refers you to specialists. For a list of Medi-Cal providers in your medical group, search the SFHP Provider Directory.

Remember that you can continue to see providers who accept your Medicare coverage, even if those providers are not SFHP providers.