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SCAN Balance (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for SCAN Balance (HMO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on SCAN Balance (HMO C-SNP) in 2025, please refer to our full plan details page.
SCAN Balance (HMO C-SNP) is a HMO C-SNP plan offered by SCAN Group available for enrollment in 2025 to people living in Bernalillo and Sandoval Counties. The overall rating for this plan is not yet available for 2025.
It's important to know that SCAN Balance (HMO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
SCAN Balance (HMO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about SCAN Balance (HMO C-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For SCAN Balance (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2800.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The SCAN Balance (HMO C-SNP) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay no copay for preferred generic drugs at any pharmacy. For standard generic drugs, you will pay a $42 copay at preferred pharmacies and a $43 copay at standard pharmacies. For preferred brand drugs, you will pay 50% coinsurance, and for non-preferred drugs, you will pay 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays. Emergency, urgent, and worldwide emergency services are covered with copays ranging from $10 to $250. The plan also covers primary care, hearing, vision, and dental services, with copays for exams and specific services. Additional benefits include ambulance and transportation services, partial hospitalization, and home health services. You will also find coverage for home infusion, dialysis, medical equipment, diagnostic and radiological services, and skilled nursing facility care. Other covered services include acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $150 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $150 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, ambulatory surgical center services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $175, while ambulatory surgical center services have no copay. Outpatient substance abuse services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor referral. There is a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $250 copay. Transportation Services to a plan-approved health-related location are covered for up to 24 one-way trips per year, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the SCAN Balance (HMO C-SNP) plan. For Emergency Services, the copay is $90, and there is no coinsurance. Urgently Needed Services have a $10 copay and no coinsurance. Worldwide Emergency Coverage has a $90 copay, Worldwide Urgent Coverage has a $10 copay, and Worldwide Emergency Transportation has a $250 copay, with no coinsurance for any of these services.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a copay between $0 and $20, other healthcare professional services with a copay between $0 and $20, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay between $0 and $20, and opioid treatment program services. Mental health and psychiatric individual and group sessions, and podiatry services are not covered.
Preventive Services See details
The SCAN Balance (HMO C-SNP) plan covers preventive services, including annual physical exams, health education, personal emergency response systems, in-home support services, support for caregivers, fitness benefits, remote access technologies, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits. However, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services are covered, including hearing exams and prescription hearing aids, but OTC hearing aids are not covered. Hearing exams have a $20 copay, and prescription hearing aids have a copay between $550 and $850.
Vision Services See details
The SCAN Balance (HMO C-SNP) plan covers vision services including eye exams with a $20 copay, and eyewear with a combined maximum of $250 every year, but upgrades are not covered. The plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $20 copay, oral exams (2 visits per year), dental x-rays (1 per year), other diagnostic dental services, prophylaxis (cleaning) (2 visits per year), restorative services, adjunctive general services, endodontics, periodontics, and oral and maxillofacial surgery. Fluoride treatment, prosthodontics (removable, fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic Services have a maximum plan benefit coverage of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. Medicare Part B Insulin Drugs have a $35 copay, and all services have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the SCAN Balance (HMO C-SNP) plan and require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the SCAN Balance (HMO C-SNP) plan, with no copay for Durable Medical Equipment (DME), but a coinsurance between 0% and 20%, and Prosthetic Devices, Medical Supplies, and Diabetic Therapeutic Shoes/Inserts each with a 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by SCAN Balance (HMO C-SNP). Diagnostic services do not have a copay, while Diagnostic Radiological Services have a maximum copay of $175.00, and Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the SCAN Balance (HMO C-SNP) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but some services are not covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, requiring prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $75. Additional days beyond Medicare-covered SNF stays, and non-Medicare-covered SNF stays, are not covered.
Other Services See details
Under Other Services, SCAN Balance (HMO C-SNP) covers acupuncture with a $15 copay, and covers over-the-counter (OTC) items with a maximum benefit of $60 every three months, including nicotine replacement therapy and naloxone. The plan also covers a meal benefit, and other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, and more are not covered.
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