Medicare and Medi-Cal: How Dual Coverage Works with SFHP
Members with both Medicare and Medi-Cal coverage are known as “dual-eligible members.” You might get Medicare and Medi-Cal coverage from separate health plans, or get all your coverage in one Dual Eligible Special Needs Plan (D-SNP).
Learn how your coverage works, who pays for your care, and how SFHP can help make your health care simple.
Get Help to Understand Your Coverage
As a dual-eligible member with both Medicare and Medi-Cal, Medicare is your main insurance. Medicare always pays before Medi-Cal pays for your care.
Do you have Medi-Cal coverage with SFHP, and Medicare coverage with a different health plan? This means that SFHP will only pay for the care that Medi-Cal covers.
Medicare is separate from Medi-Cal and has different rules. To learn more about your coverage, read the documents that came from your Medicare plan or the Medicare program.
Or, visit medicare.gov to learn more.
What Medi-Cal Care Does SFHP Cover?
SFHP pays for care covered by Medi-Cal that your Medicare insurance does NOT pay for.
The Medi-Cal care that SFHP pays for depends on the Medicare coverage you have.
Do you have Original Medicare Part A only?
- Medicare Part A covers hospital care, but not doctor’s visits and other outpatient care.
- SFHP will cover outpatient care that you get from in-network SFHP providers. You may need prior authorization (pre-approval) from SFHP to see an out-of-network doctor.
Do you have Original Medicare Part B only?
- Medicare Part B covers outpatient care, but not hospital care.
- SFHP will cover care that you get from in-network SFHP hospitals. You may need pre-approval from SFHP to get non-emergency care at an out-of-network hospital.
Do you have Original Medicare Parts A and B, or a Part C Medicare Advantage Plan?
- SFHP will pay for care covered by Medi-Cal that your Medicare insurance does NOT pay for.
To learn more about your Medi-Cal benefits, check your SFHP Member Handbook.
What Medi-Cal Providers Can I Visit?
First, check the front of your SFHP Member ID Card to find your medical group.
If your medical group is SFHP Direct Network (SDN):
- You do not have to choose a primary care provider (PCP)*.
- You can get care from any in-network SFHP provider in any medical group. To find available Medi-Cal providers, search the SFHP Provider Directory. You can search by zip code, type of provider, and more.
If your medical group is not SDN:
- You will choose or be assigned a PCP who manages your care. Your PCP can also refer you to specialists (expert doctors in one type of health care).
- To find in-network Medi-Cal providers, search the SFHP Provider Directory. You can search by your medical group, zip code, type of provider, and more.
Medicare + Medi-Cal, All in One Plan: SFHP Care Plus
Already have Medi-Cal with San Francisco Health Plan (SFHP)? Now, you can get your Medicare and Medi-Cal coverage all in one plan with SFHP Care Plus (HMO D-SNP).
With SFHP Care Plus, you get Medicare + Medi-Cal together, plus extra benefits for $0 and personalized support. And it’s all from SFHP, your local health plan for nearly 30 years and SF’s #1 choice for Medi-Cal.
Want to sign up for SFHP Care Plus—or already a member? To enroll, view your benefits and more, visit sfhp.org/care-plus.
*Your primary care provider (PCP) is your personal doctor if you need a check-up, want advice about a health problem, or get sick or hurt.
If you need help or have questions, call SFHP Customer Service at