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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 Santa Clara and Stanislaus Counties. This plan received an overall rating of 4.5 out of 5 stars in 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 $1200.00 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. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have a $42 copay at preferred pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers a range of benefits with varying costs. Inpatient hospital stays have copays, with no copay for most days. Outpatient services have copays, while ambulance services have a $100 copay. Emergency services have a $90 copay, and primary care services have copays of $5-$10. The plan covers preventive services, hearing, vision, and dental services with specific limitations and costs. Hearing aids have copays between $550 and $850. The plan also covers home infusion, dialysis, medical equipment, and home health services with different cost-sharing arrangements. Other services, such as acupuncture and OTC items, are covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with a doctor referral and prior authorization required. For Inpatient Hospital-Acute, there is no copay for days 1-4 and 11-90, but there is a $75 copay for days 5-10. For Inpatient Hospital Psychiatric, there is no copay for days 1-4 and 11-90, but there is a $75 copay for days 5-10. Additional days for Inpatient Hospital-Acute are covered with no copay, but additional days for Inpatient Hospital Psychiatric are not covered, as are Non-Medicare-covered stays and upgrades for both.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $100, and individual and group sessions for outpatient substance abuse have a copay of $10.
Partial Hospitalization See details
Partial Hospitalization is covered under the SCAN Balance (HMO C-SNP) plan, with a $55 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no coinsurance. Ground and Air Ambulance Services each have a $100 copay. Transportation Services to any health-related location are covered for 28 one-way trips per year, but other transportation services are 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. Emergency Services and Worldwide Emergency Coverage have a $90 copay, while Worldwide Emergency Transportation has a $100 copay; all other services have no copay and no coinsurance.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers primary care, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Routine chiropractic care has a $5 copay. Individual and group sessions for mental health and psychiatric services have a $10 copay.
Preventive Services See details
Preventive services are covered by the SCAN Balance (HMO C-SNP) plan. The plan covers services like Health Education, In-Home Safety Assessments, Personal Emergency Response Systems, In-Home Support Services, Support for Caregivers of Enrollees, Fitness Benefits, Remote Access Technologies, Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following Welcome Visits.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered for 1 visit per year, and fitting/evaluation for hearing aids is unlimited. Prescription hearing aids have a copay between $550 and $850, and are covered for 2 per year. Prescription hearing aids are not covered for inner ear, outer ear, or over the ear. OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams, eyewear, and contact lenses. Routine eye exams are covered once per year, eyewear has a combined maximum benefit of $300 every two years, and contact lenses are covered once every two years.
Dental Services See details
The SCAN Balance (HMO C-SNP) plan covers a variety of dental services. This includes oral exams (2 visits per year), dental x-rays (1 per year), other diagnostic dental services, and prophylaxis (cleaning) (2 per year). However, fluoride treatment, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. Orthodontic services are covered with a maximum benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay, and coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the SCAN Balance (HMO C-SNP) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics, and Medical Supplies, is covered by the SCAN Balance (HMO C-SNP) plan. DME has a coinsurance between 0% and 20% with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a coinsurance between 0% and 20% with no copay, and Medical Supplies have a coinsurance between 0% and 20% with no copay. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
The SCAN Balance (HMO C-SNP) plan covers diagnostic and radiological services, but diagnostic procedures/tests, lab services, and outpatient X-ray services are not covered. Diagnostic Radiological Services have a copay of at most $100, and Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the SCAN Balance (HMO C-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires prior authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are 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 with prior authorization and a doctor's referral. There is no copay for days 1-20, and a $50 copay for days 21-100.
Other Services See details
The SCAN Balance (HMO C-SNP) plan covers acupuncture with a $5 copay, and also covers over-the-counter (OTC) items with a maximum benefit coverage amount of $70 every three months. The plan also covers meal benefits. However, the plan does not cover Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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