Download Valley Care Description of Services

Valley Care
Description of Services
October 2007 - 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 1.888.363.3394. 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
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 1.888.363.3394 or go to the Valley Care web
page at www.scvmed.org/valleycare.
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 1.888.334.1000 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
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 1.888.334.1000 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 95128. 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 1.888.334.1000.
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


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
1.888.363.3394, located at Santa Clara Valley Medical Center, 751 S. Bascom Avenue, San Jose,
CA 95128. 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
1.888.363.3394 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
Valley Care
Description of Services
Service
Provided
Co-payment (Co-pay)
Acupuncture
Yes
Adult Periodic Health Examinations and
Screenings (Immunizations, Pap Smears,
PSA, Mammogram, and all tests
recommended by your PCP).
Ambulance Services
Ambulatory Surgery (Outpatient)
Yes
Ancillary Services, laboratory, diagnostic
imaging, radiology, EKG, EEG, echo, etc.
Breast Pumps (electronic)
Chemotherapy Infusion
Yes
Chiropractic
C-pap masks – Bi-pap
No
Yes
Dental Care – at SCVMC dentists only
Office Visit
Diabetic Testing Supplies
Emergency
Only
Yes
None
Dialysis at Home - Continuous Ambulatory
Peritoneal Dialysis (CAPD)
Yes
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
SCVMC Network
Providers
Disease Management Services
Yes
None
SCVMC Network
Providers
Valley Care - October 2007, Issue No. 1
SCVMC only, requires prior
approval.
Based on FPL
0–100% = $0/visit
101-200% = $5/visit
0-100% Homeless = $0/visit
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
Not applicable
Based on FPL
0-100% = $25/surgery
101-200% = $50/surgery
0-100% Homeless = $0/surgery
If admitted to SCVMC,
outpatient co-pay is waived.
However, the Inpatient Hospital
co-pay will apply.
None
Location
No
Yes
No
Yes
Not applicable
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
Not applicable
None
5
None
Not applicable
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
SCVMC Network
Providers
SCVMC Network
Providers
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).
Emergency Care
Yes
None
SCVMC Network
Providers
Yes
Based on FPL
0-100% = $25/visit
101-200% = $50/visit
0-100% Homeless = $0/visit
SCVMC Only
Routine care provided in the
Emergency Dept. will require a
co-pay.
Emergency Mental Health Services
If admitted to SCVMC from the
SCVMC Emergency Dept., the
Emergency Care co-pay is
waived. However, the Inpatient
Hospital co-pay will apply.
Based on FPL
0-100% +$50/admit
101-200% = $100/admit
0-100% Homeless = $0/visit
Yes
Enteral/ Parenteral Nutrition
Yes
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.
None
Eye Glasses
No
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.
Yes
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
None
Valley Care - October 2007, Issue No. 1
Yes
6
SCVMC Network
Providers
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
SCVMC Network
Providers
Service
Provided
Co-payment (Co-pay)
Location
Health Promotions Services not offered by
SCVMC staff such as Yoga, Exercise
classes, Weight Watchers, etc.
Home Visits
No
Not applicable.
Not applicable
Yes
$5/visit
Infertility
Immunizations
No
Yes
Not applicable
None
Inpatient Hospital Care
Yes
Medical Supplies - Medically Necessary
Yes, When
Prescribed &
Medically
Necessary
No
Based on FPL
0-100% =$50/admit
101-200% = $100/admit
0-100% Homeless = $0/visit
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
SCVMC
Routine Mental Health Services
Organ Transplant
Outpatient Hospital Services as Medically
Necessary
No
Yes
Over the Counter Drugs
Prenatal Care/Exams
First visit until the patient is enrolled in
Medi-Cal
No
Yes
One Visit
Prescription Drugs (only those listed on the
SCVMC formulary)
Yes
Mail order option, if available.
Not applicable
Not applicable
Not applicable
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
Not applicable
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
None for covered drugs on the
SCVMC Formulary.
Not applicable
SCVMC Network
Providers
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).
Primary Care Services/Visit to the Doctor,
Includes outpatient services and medically
necessary physical examinations.
Yes
Prosthetic Devices, corrective appliances,
and artificial aids
Yes None
Valley Care - October 2007, Issue No. 1
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
7
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
SCVMC Network
Providers – 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.
SCVMC Network
Providers – See the
Primary Care Physician
List included in the
enrollment packet.
SCVMC Network
Providers
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
Yes
Patches only
dispensed in
conjunction
with classes.
None
SCVMC Network
Providers
Therapy Services (physical, occupational,
speech, respiratory), Renal Dialysis,
Tuberculosis, Oncology/Infusion/Radiation
Therapy
Total Parenteral Nutrition
Yes
None
SCVMC Network
Providers
Yes
None
Travel Immunizations
Urgent Care
No
Yes
Specialty Care (cardiology, dermatology,
surgery, etc.), when determined to be
medically necessary
Yes
Not applicable
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
Based on FPL
0-100% = $5/visit
101-200% = $10/visit
0-100% Homeless = $0/visit
SCVMC Network
Providers
Not applicable
SCVMC Network
Providers
SCVMC Network
Providers
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
Valley Health Centers
FAI
RO
AK
S
ON
KS
JAC
EL
CA
Sunnyvale
E
KE
Mc
MIN
O
C
MOORPARK
San Jose
BASCOM
THORNTON
HAMILTON
K
ER
EE
NT
CR
SE
R
VE
IT
AP
SIL
OL
Y
LL
TU
FRUITDALE
CAMINO ARROYO
Gilroy
E. 6TH
GILMAN
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
1.888.363.3394
8487 REV 3/09