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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 Alameda and San Mateo 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 $1500.00 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) Medicare plan features 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, compared to a $10 copay at standard pharmacies. For Tier 2 standard generic drugs, you will pay a $42 copay at preferred pharmacies or a $47 copay at standard pharmacies, while Tier 3 and Tier 4 drugs require a 35% and 30% coinsurance respectively. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D drugs. Additionally, individuals who qualify for the low-income subsidy, also known as Extra Help, will pay $0 for their Part D premium. Be sure to check the SCAN Balance (HMO C-SNP) formulary to ensure your specific medications are covered.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers robust medical coverage with affordable cost-sharing, featuring no copay for preventive services, urgent care, and the first 20 days in a skilled nursing facility. Inpatient hospital stays require a $100 daily copay for the first five days, while emergency room visits carry a $90 copay that is waived if you are admitted. Outpatient hospital services are available with a $125 copay, and mental health therapy sessions feature a low $10 copay with no coinsurance. This plan also includes valuable supplemental benefits, such as dental coverage up to a $3,000 annual limit, routine vision exams with a $250 eyewear allowance, and up to 30 one-way transportation trips per year. Hearing care is covered for routine exams and includes a copay of $550 to $850 for up to two prescription hearing aids annually. Additionally, members benefit from a $30 monthly over-the-counter allowance and acupuncture coverage for up to 36 treatments per year.
Inpatient Hospital See details
Inpatient hospital services are partially covered by SCAN Balance (HMO C-SNP), excluding upgrades, non-Medicare-covered stays, and additional psychiatric days. Acute stays require a $100 daily copay for days 1 through 5 and no copay for days 6 through 90, while psychiatric stays require a $250 daily copay for days 1 through 6 and no copay for days 7 through 90, with no coinsurance required for either service.
Outpatient Services See details
Outpatient services are covered by SCAN Balance (HMO C-SNP) with no coinsurance, featuring a $125 copay for outpatient hospital services and a $10 copay for outpatient substance abuse sessions. Ambulatory surgical center and outpatient blood services are also covered with no deductible, though prior authorization and a doctor referral are required for most of these benefits.
Partial Hospitalization See details
Partial hospitalization benefits are covered by SCAN Balance (HMO C-SNP), requiring prior authorization and a doctor referral. While these services are covered, specific copay and coinsurance details are not specified in the plan terms.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by SCAN Balance (HMO C-SNP), featuring a $180 copay and no coinsurance for ground and air ambulance trips. Transportation benefits are partially covered, providing up to 30 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 under the SCAN Balance (HMO C-SNP) plan with a $90 copay and no coinsurance, with the copay waived if you are admitted to the hospital. Urgently needed services require no copay and no coinsurance, while worldwide emergency coverage and emergency transportation are covered with copays of $90 and $180, respectively, and no coinsurance.
Primary Care See details
Primary care is partially covered by SCAN Balance (HMO C-SNP) because podiatry services are not covered. Covered services include doctor visits, chiropractic care, and therapy, with a $10 copay and no coinsurance for mental health, psychiatric, and opioid treatment sessions.
Preventive Services See details
SCAN Balance (HMO C-SNP) covers preventive services with no copay and no coinsurance, including annual physical exams and kidney disease education. However, additional preventive services are only partially covered, excluding medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, tobacco cessation, disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by SCAN Balance (HMO C-SNP), as OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered. Covered benefits include routine exams and fitting evaluations with no deductible, as well as up to two prescription hearing aids per year with a copay of $550 to $850 and no coinsurance.
Vision Services See details
Vision services are partially covered by SCAN Balance (HMO C-SNP), providing one routine eye exam and a $250 annual eyewear allowance with no deductible, though eyewear upgrades are not covered and specific copay or coinsurance details are not specified.
Dental Services See details
Dental services are partially covered by SCAN Balance (HMO C-SNP), as orthodontics is not covered. The plan covers preventive care and various comprehensive services up to a $3,000 annual limit, though prior authorization is required for many treatments.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by SCAN Balance (HMO C-SNP) with prior authorization, requiring no copay and no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Medicare Part B insulin drugs are covered with a $35 copay and 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 access these services.
Medical Equipment See details
Medical equipment is partially covered by the SCAN Balance (HMO C-SNP) plan, with covered services such as durable medical equipment, prosthetic devices, and medical supplies requiring no copay and 0% to 20% coinsurance. Diabetic supplies and diabetic therapeutic shoes or inserts are not covered under this plan, and prior authorization is required for covered equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the SCAN Balance (HMO C-SNP) plan, with therapeutic radiological services requiring a $60 copay and no coinsurance. Diagnostic procedures and tests, lab services, diagnostic radiological services, and outpatient x-ray services are not covered.
Home Health Services See details
Home Health Services are covered under the SCAN Balance (HMO C-SNP) plan, requiring both prior authorization and a doctor referral to receive care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the SCAN Balance (HMO C-SNP) plan, with no coverage, copay, or coinsurance provided for cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by SCAN Balance (HMO C-SNP), featuring no copay and no coinsurance for days 1 through 20, and a $75 daily copay with no coinsurance for days 21 through 100. Prior authorization and a doctor referral are required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
SCAN Balance (HMO C-SNP) partially covers other services, which include acupuncture up to 36 treatments per year, post-hospitalization meal benefits, and a $30 monthly over-the-counter allowance. Highly integrated services for dual-eligible SNPs are not covered, and specific copay or coinsurance information is not specified for the covered benefits.
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