Valley Care. Description of Services. October Issue No.1

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2 Valley Care Description of Services October Issue No.1 Valley Care Introduction Valley Care is a program designed by Santa Clara County to provide access to health care for Santa Clara County residents who are United States Citizens and ineligible for other publicly funded health care insurance. This program is designed to ensure that each participant receives high quality, timely services from a committed health care team of physicians, mid-level providers, nurses, medical assistants, health educators and other providers in Santa Clara County. Santa Clara Valley Medical Center (SCVMC) is the only hospital that provides services covered by Valley Care. Low co-payments and no required premiums are designed to provide affordable health care services, including preventative services. These affordable services are offered within a variety of settings through Santa Clara Valley Medical Center s network of providers. Co-payments are based on income and services are obtained through a Primary Care Physician (PCP) who will assist the participant in managing his/her care. Valley Care is not insurance, it is a health care program that provides coverage with public funds. This Description of Services booklet is a guide to Valley Care health services available through Santa Clara Valley Medical Center (SCVMC) and its network of providers. SCVMC will manage all eligibility and co-payments. How to Enroll in the Valley Care Program Enrollment is required before you can receive medical services covered by Valley Care. Forms can be obtained by calling a Valley Care Representative at Once enrolled, you must continue to meet the Valley Care requirements and access care through a designated Primary Care Physician (PCP). You will be assigned a PCP if you do not have one. See below section, Eligibility Requirements for Participation. If eligibility requirements are not met, enrollment is not possible. Eligibility Requirements for Participation If you want to enroll in the Valley Care Program, you must meet the following eligibility requirements: You must be a resident of Santa Clara County. A person is considered to be a resident of Santa Clara County when he/she has no other place of residence outside of Santa Clara County and is physically present in this County and is able to prove that he/she does reside in this County. Visitors, students, tourists, and others who have residency outside of Santa Clara County are not eligible; You must not be eligible for any publicly funded health insurance programs such as Medi-Cal, Healthy Families or Medicare; You must not have been covered by any insurance for 90 days; Valley Care - October 2007, Issue No. 1 1

3 Eligibility Requirements for Participation Continued You must be between 19 and 64 years of age; You must be a documented U.S. citizen or a national; You must complete an enrollment form; Your annual income must be at or below the 200% of the Federal Poverty Level (FPL); Eligibility period is from the date you provide the required documentation, i.e. proof of US citizenship, verification of income and Santa Clara County residency, and is for one year from your original effective date; Financial status will be verified once a year. Customer Service Once enrolled in Valley Care, questions or concerns should be referred to Santa Clara Valley Medical Center s Customer Service Department at or go to the Valley Care web page at Co-payments and Other Charges A list of co-payments for covered services is listed in this booklet. To avoid additional charges, co-payments must be made at the time of service(s). A $25.00 service charge will be added to a bill sent to those participants who do not pay their co-payment at the time of service(s). Accessing Services As a participant, you are selecting the Valley Care network as your provider of health care. You must receive all covered services from the Valley Care network. You will have convenient access to all of the covered services you may need such as routine care with your Primary Care Physician (PCP), hospital care, laboratory, radiology, pharmacy and other services. To ensure quality health care, you should regularly schedule general checkups and office visits. If you go outside the Valley Care network for care, Valley Care will not pay for these services. Once enrolled, you, the participant, will receive an identification card, access to services, health education information, and a list of participating providers. You will be assigned to a Primary Care Physician (PCP) if you do not have one already in the Valley Care network. All participating providers are part of Santa Clara Valley Medical Center (SCVMC) and the Valley Care network of providers. A Valley Care identification card does not guarantee access to services; you must continue to meet all eligibility requirements and ensure care is received through your designated Primary Care Physician (PCP). Your PCP will make arrangements for you to see specialist physicians or to be admitted to Santa Clara Valley Medical Center (SCVMC). Routine Care For routine care, you should make an appointment with your Primary Care Physician (PCP). For PCP s at Valley Health Center Locations, call or the appointment number listed for your Valley Care network PCP. Your PCP will coordinate all routine, specialty care, laboratory, radiology, therapy or other covered services. Valley Care - October 2007, Issue No. 1 2

4 Specialty Care Your Primary Care Physician will request specialty services for you if medically necessary. Your PCP will provide you with the phone number to call to make your appointment. You will be responsible for making your specialty appointments once approved. Self-Referral Services OB/GYN Services - Any female participant may self-refer to a SCVMC or Valley Care network OB/GYN. For an appointment, call or the appointment number listed for your Valley Care network provider. Inpatient Hospital Services Your selection of Valley Care means your hospital is Santa Clara Valley Medical Center (SCVMC) which is located at 751 South Bascom Avenue, San Jose, CA Your Primary Care Physician or SCVMC Hospital Physician will arrange for all covered inpatient hospital services. Emergency & Urgently Needed Services In the event of an emergency, only services at Santa Clara Valley Medical Center (SCVMC) will be covered. If you are admitted to SCVMC, all emergency care co-pays are waived. Inpatient co-pays will apply. If your visit is not a medical emergency, you will have to pay a co-pay based on your income. In the event that you have an emergency and you are taken to a hospital other than Santa Clara Valley Medical Center, Valley Care will not pay for those services. Emergency Services are available at Santa Clara Valley Medical Center (SCVMC), 24 hours a day, 7 days a week. SCVMC clinics offer extended hours for urgent care. Advice on how to obtain Urgently Needed Services is available through Valley Connection (appointments & medical advice) 24 hours a day, 7 days a week by calling Ambulance transportation costs are not covered by Valley Care. Prescription Drugs, Medication and Pharmacy Services When you receive a prescription from a Valley Care provider, you must have it filled at a SCVMC network pharmacy. Prescription drugs are limited to prescriptions written by a Valley Care provider when deemed medically necessary. There is no charge for drugs that are on the SCVMC formulary or if a Non-Formulary Drug Request (NFDR) is received from a Valley Care provider and approved for use by the SCVMC Medical Director or designee. The SCVMC Formulary is a list of medications approved for use by the SCVMC medical staff. Pharmacy Locations: See the Santa Clara Valley Health Center map included in this booklet for Valley Care network pharmacy locations. Pharmacies are located at the Valley Specialty Center and the Valley Health Centers. Valley Care participants must pay for Non-Formulary drugs that are not authorized, drugs not on the Formulary, Lifestyle drugs and Over the Counter (OTC) drugs. (Lifestyle drugs are medications that are considered optional and not medically necessary to improve health status, such as erectile dysfunction drugs like Viagra and Cialis.) Denial and Termination of Valley Care Program Enrollment As a participant (patient), you may be terminated from Valley Care for the following reasons: Valley Care - October 2007, Issue No. 1 3

5 If, after reasonable efforts, any Valley Care participant or any Valley Care provider network staff is unable to establish and maintain a satisfactory hospital-patient or physician-patient relationship; Providing incomplete, erroneous, misleading, or otherwise fraudulent information; Denial and Termination of Valley Care Program Enrollment Continued If a Valley Care participant fails to fully pay any required co-pays without making prior arrangements with the Santa Clara Valley Medical Center (SCVMC) Business Office; Change in eligibility status. If you are terminated from Valley Care, you will be mailed a written notice of termination at least thirty (30) calendar days before the proposed effective date of termination specifying the reasons for termination and giving you ten (10) calendar days from the date of the written notice to respond (orally or in writing) to the Santa Clara Valley Medical Center Customer Service at , located at Santa Clara Valley Medical Center, 751 S. Bascom Avenue, San Jose, CA In the event that it is determined that fraudulent or misleading information was provided, termination may be retroactive to the first date of coverage. You or someone on your behalf may contact the SCVMC Customer Service Department at to challenge the termination. Customer Service will then review the situation and make a written recommendation to the Valley Care administration. If it is determined that the termination stands, you have no recourse other than to re-apply for participation in the program. Re-applying for participation in Valley Care does not guarantee enrollment. If you were terminated for cause or you do not meet the participation and eligibility requirements, enrollment is not available. Valley Care - October 2007, Issue No. 1 4

6 Valley Care Description of Services Service Provided Co-payment (Co-pay) Location Acupuncture SCVMC only, requires prior approval % = $0/visit % = $5/visit Adult Periodic Health Examinations and Screenings (Immunizations, Pap Smears, PSA, Mammogram, and all tests recommended by your PCP). Not applicable Ambulance Services No Not applicable Not applicable Ambulatory Surgery (Outpatient) 0-100% = $25/surgery % = $50/surgery 0-100% Homeless = $0/surgery If admitted to SCVMC, outpatient co-pay is waived. However, the Inpatient Hospital co-pay will apply. Ancillary Services, laboratory, diagnostic imaging, radiology, EKG, EEG, echo, etc. None Breast Pumps (electronic) No Not applicable Not applicable Chemotherapy Infusion Chiropractic No Not applicable Not applicable C-pap masks Bi-pap None Dental Care at SCVMC dentists only Office Visit Emergency Only None Diabetic Testing Supplies None Dialysis at Home - Continuous Ambulatory Peritoneal Dialysis (CAPD) Disease Management Services None Valley Care - October 2007, Issue No. 1 5

7 Service Provided Co-payment (Co-pay) Location Drug and Alcohol Abuse Services Available through County Drug and Alcohol Services Not applicable Not applicable Durable Medical Equipment (Crutches, Walker, Nebulizer, Basic wheelchair, and any other items determined medically necessary by the Valley Care Medical Director or designee). None Emergency Care 0-100% = $25/visit % = $50/visit Routine care provided in the Emergency Dept. will require a co-pay. SCVMC Only If admitted to SCVMC from the SCVMC Emergency Dept., the Emergency Care co-pay is waived. However, the Inpatient Hospital co-pay will apply. Emergency Mental Health Services 0-100% +$50/admit % = $100/admit If admitted to SCVMC from SCVMC Emergency Dept. or Emergency Psychiatric Services (EPS), the Emergency Care copay is waived, however, the Inpatient Hospital co-pay will apply. Enteral/ Parenteral Nutrition None Eye Glasses No Not applicable Not applicable Eye Services: only screenings for medical conditions and other medically necessary diagnosis, treatment, and surgery will be covered. Health Education Services such as Smoking Cessation, Prenatal, Parenting, Breastfeeding, etc. provided by SCVMC staff. Valley Care - October 2007, Issue No. 1 6 None

8 Service Provided Co-payment (Co-pay) Location Health Promotions Services not offered by No Not applicable. Not applicable SCVMC staff such as Yoga, Exercise classes, Weight Watchers, etc. Home Visits $5/visit Infertility No Not applicable Not applicable Immunizations None Inpatient Hospital Care 0-100% =$50/admit % = $100/admit Medical Supplies - Medically Necessary, When Prescribed & Medically Necessary SCVMC Routine Mental Health Services No Not applicable Not applicable Organ Transplant No Not applicable Not applicable Outpatient Hospital Services as Medically Necessary Over the Counter Drugs No Not applicable Not applicable Prenatal Care/Exams First visit until the patient is enrolled in Medi-Cal One Visit Prescription Drugs (only those listed on the SCVMC formulary) Mail order option, if available. None for covered drugs on the SCVMC Formulary. None for non-formulary drugs if a Non-Formulary Drug Request (NFDR) is approved. Patient pays for unapproved Non-formulary drugs, Lifestyle drugs and Over the Counter (OTC). See the Santa Clara Valley Health Center map included in this booklet for Valley Care network pharmacy locations. Pharmacies are located at the Valley Specialty Center and the Valley Health Centers. Primary Care Services/Visit to the Doctor, Includes outpatient services and medically necessary physical examinations. Prosthetic Devices, corrective appliances, and artificial aids None See the Primary Care Physician List included in the enrollment packet. Valley Care - October 2007, Issue No. 1 7

9 Service Provided Co-payment (Co-pay) Location Services/Surgery not provided at SCVMC, examples include, cardiovascular surgery, lithotripsy, organ transplant etc. No Not applicable Not applicable Smoking Cessation Patches only dispensed in conjunction with classes. None Therapy Services (physical, occupational, speech, respiratory), Renal Dialysis, Tuberculosis, Oncology/Infusion/Radiation Therapy None Total Parenteral Nutrition None Travel Immunizations No Not applicable Not applicable Urgent Care Specialty Care (cardiology, dermatology, surgery, etc.), when determined to be medically necessary To avoid additional charges, co-payments must be made at the time of service(s). A $25.00 service charge will be added to a bill sent to those participants who do not pay their co-payment at the time of service(s). Valley Care - October 2007, Issue No. 1 8

10 Valley Health Centers FAIR OAKS Sunnyvale JACKSON McKEE EL CAMINO SILVER CREEK TULLY CAPITOL SENTER THORNTON HAMILTON BASCOM MOORPARK FRUITDALE San Jose Gilroy E. 6TH GILMAN CAMINO ARROYO Santa Clara Valley Medical Center 751 S. Bascom Ave., San Jose Bus #25, #61, #62 Valley Specialty Center 751 S. Bascom Ave., San Jose Bus #25, #61, #62 Valley Health Center Bascom 750 S. Bascom Ave., San Jose Bus #25, #61, #62 Valley Health Center East Valley 1993 McKee Rd., San Jose Bus #64, #70 Valley Health Center Gilroy 7475 Camino Arroyo, Gilroy Bus #17 Valley Health Center Moorpark 2400 Moorpark Ave., San Jose Bus #25, #61, #62 Valley Health Center Silver Creek 1620 E. Capital Expwy., San Jose Bus #31, #70 Valley Health Center Sunnyvale 660 S. Fair Oaks Ave., Sunnyvale Bus #22, #55, #522 Valley Health Center Tully 500 Tully Rd., San Jose Bus #26 Dedicated to the Health of the Whole Community

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