Members with 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.
