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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 2026, 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 out of 5 stars in 2026.
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 a $250.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $750.00 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 offers an Enhanced Alternative drug benefit with a $250 prescription drug deductible. After meeting this deductible, you will pay no copay for Tier 1 preferred generic drugs at preferred pharmacies or through preferred mail order, while standard options cost a $10 copay. Tier 2 standard generic drugs require a $42 copay at preferred pharmacies and mail order, or a $47 copay at standard pharmacies and standard mail. For higher tiers, you will pay a 35% coinsurance for Tier 3 preferred brand drugs and a 30% coinsurance for Tier 4 non-preferred drugs across all pharmacy types. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D prescription drugs. If you qualify for the low-income subsidy, your Part D premium cost may also be reduced to $0.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers comprehensive medical coverage with no copay for acute inpatient hospital stays and zero-dollar Medicare-covered preventive services. Outpatient hospital services range from no copay up to a $100 copay, while emergency care requires a $90 copay that is waived upon hospital admission. Additionally, members benefit from no copays for urgent care and a flat $10 copay for outpatient mental health and substance abuse sessions. For specialized care, the plan provides unlimited preventive dental services alongside comprehensive dental coverage up to a $3,000 annual limit. Vision benefits include a routine eye exam and a $250 annual eyewear allowance with no deductible, while prescription hearing aids require a copay between $550 and $850. Members also receive extra perks like up to 40 one-way transportation trips per year, a $50 monthly over-the-counter allowance, and unlimited acupuncture.
Inpatient Hospital See details
Inpatient hospital services are partially covered by SCAN Balance (HMO C-SNP) with no coinsurance, featuring no copay for acute stays and psychiatric days 1 through 4 and 11 through 90, but requiring a $75 daily copay for psychiatric days 5 through 10. Prior authorization and doctor referrals are required, while upgrades and non-Medicare-covered stays for acute care, as well as additional days and non-Medicare-covered stays for psychiatric care, are not covered.
Outpatient Services See details
SCAN Balance (HMO C-SNP) covers outpatient services with copays ranging from no copay up to $100 for hospital services, and a flat $10 copay for outpatient substance abuse sessions. There is no coinsurance or deductible for these services, though prior authorization and doctor referrals are required for most benefits.
Partial Hospitalization See details
Partial hospitalization is covered by SCAN Balance (HMO C-SNP) with a $55 copay and no coinsurance. Prior authorization and a doctor referral are required to access these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by SCAN Balance (HMO C-SNP), with ground and air ambulance services requiring a $100 copay and no coinsurance. Transportation services are partially covered, offering up to 40 one-way trips per year to plan-approved health-related locations, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by SCAN Balance (HMO C-SNP) with a $90 copay and no coinsurance, which is waived if you are admitted to the hospital. Urgently needed services have no copay and no coinsurance, while worldwide emergency services are covered with a $90 copay for emergency care, a $100 copay for transportation, and no coinsurance.
Primary Care See details
Primary Care benefits are partially covered by SCAN Balance (HMO C-SNP), as podiatry services are not covered. Covered psychiatric, mental health specialty, and opioid treatment services require a $10 copay and no coinsurance, while most other services require prior authorization and a doctor referral.
Preventive Services See details
Preventive services are covered by SCAN Balance (HMO C-SNP) with no copay and no coinsurance for Medicare-covered zero-dollar preventive services. This benefit is partially covered, as sub-services including Medical Nutrition Therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for chemotherapy hair loss, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, home and bathroom safety devices, counseling, and additional smoking cessation sessions are not covered.
Hearing Services See details
Hearing services are partially covered by SCAN Balance (HMO C-SNP), which includes one annual routine hearing exam and unlimited fitting evaluations. Covered prescription hearing aids (all types) require a copay of $550 to $850 and no coinsurance for up to two devices per year, but inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered.
Vision Services See details
SCAN Balance (HMO C-SNP) provides partially covered vision services with no deductible, including one routine eye exam and a $250 annual limit for eyewear, though eyewear upgrades are not covered. Prior authorization and a doctor referral are required for exams and eyewear.
Dental Services See details
SCAN Balance (HMO C-SNP) offers dental services, which are partially covered as orthodontics is not covered. The plan features unlimited preventive services, including exams and cleanings, and covers comprehensive services up to a $3,000 annual maximum, though most comprehensive procedures require prior authorization.
Home Infusion bundled Services See details
Home infusion bundled services are covered by SCAN Balance (HMO C-SNP) with prior authorization required. Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while other covered Part B chemotherapy, radiation, and miscellaneous drugs have no copay and require no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by SCAN Balance (HMO C-SNP) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these services.
Medical Equipment See details
Medical equipment is partially covered by SCAN Balance (HMO C-SNP), as diabetic supplies are not covered. For covered items like durable medical equipment, prosthetics, and diabetic therapeutic shoes, there is no copay and coinsurance ranges from no coinsurance up to 20%.
Diagnostic and Radiological Services See details
SCAN Balance (HMO C-SNP) partially covers diagnostic and radiological services, requiring doctor referrals and prior authorization for care. While diagnostic procedures, lab services, and outpatient X-rays are not covered, covered diagnostic radiological services feature no coinsurance and a copay ranging from no copay to $100, and therapeutic radiological services require a 20% coinsurance and a copay.
Home Health Services See details
SCAN Balance (HMO C-SNP) covers Home Health Services, requiring prior authorization and a doctor referral. Copay and coinsurance information for these covered services is not specified in the plan details.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the SCAN Balance (HMO C-SNP) plan, as all associated sub-services, including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation, are not covered.
Skilled Nursing Facility (SNF) See details
SCAN Balance (HMO C-SNP) partially covers Skilled Nursing Facility (SNF) services, requiring prior authorization and a doctor referral, though additional days beyond Medicare-covered limits are not covered. Members pay no copay and no coinsurance for days 1 through 20, and a $50 copay per day with no coinsurance for days 21 through 100.
Other Services See details
Other Services are partially covered by SCAN Balance (HMO C-SNP), which includes unlimited acupuncture, meal benefits after hospitalization, and a $50 monthly over-the-counter allowance, while highly integrated services for dual-eligible SNPs are not covered. No copays or coinsurance are specified for these covered benefits, though prior authorization is required for acupuncture and meals.
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