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SCAN Affirm partnered with Included LGBTQ+ Health (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for SCAN Affirm partnered with Included LGBTQ+ Health (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on SCAN Affirm partnered with Included LGBTQ+ Health (HMO) in 2025, please refer to our full plan details page.
SCAN Affirm partnered with Included LGBTQ+ Health (HMO) is a HMO plan offered by SCAN Group available for enrollment in 2025 to people living in Los Angeles, Orange and Riverside Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that SCAN Affirm partnered with Included LGBTQ+ Health (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about SCAN Affirm partnered with Included LGBTQ+ Health (HMO).
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 Affirm partnered with Included LGBTQ+ Health (HMO), 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. Additionally, this plan comes with a Part B Premium reduction of $16.50. You must continue to pay paying your reduced 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 $199.00 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:
Sign up for SCAN Affirm partnered with Included LGBTQ+ Health (HMO)
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Drug Coverage
The SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay varying copays or coinsurance amounts depending on the drug tier and pharmacy type. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail order, while standard generic drugs have a $42 copay at preferred pharmacies. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for covered Part D drugs. If you qualify for the low-income subsidy (LIS), your monthly premium for Part D is $0.
Additional Benefits
The SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan offers a wide variety of benefits, including coverage for inpatient and outpatient services, as well as emergency services. The plan also provides coverage for primary care, preventive services, hearing, vision, and dental services, with varying copays depending on the service. Additional benefits include ambulance and transportation services, home health services, medical equipment, and other services such as acupuncture and over-the-counter items. While the plan covers many services, it's important to note that some services like certain outpatient substance abuse services, individual mental health sessions, and some vision and dental services may not be covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days for Inpatient Hospital-Acute are covered, while Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Blood Services. Outpatient Substance Abuse Services are partially covered; Individual Sessions and Group Sessions for Outpatient Substance Abuse are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered with a $10 copay, and requires prior authorization and a doctor's referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground and air ambulance services each have a $200 copay, and there is no coinsurance. Transportation services to a plan-approved health-related location are covered for up to 20 one-way trips per year, and transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by SCAN Affirm partnered with Included LGBTQ+ Health (HMO). Emergency Services and Worldwide Emergency Coverage have a $90 copay, and Worldwide Emergency Transportation has a $200 copay, while Urgently Needed Services have no copay. There is no coinsurance for any of these services.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services require a doctor referral and prior authorization, with a limit of 30 visits per year. Occupational Therapy Services and Physical Therapy and Speech-Language Pathology Services require prior authorization and a doctor referral, but have no copay or coinsurance. Individual and Group Sessions for Mental Health and Psychiatric Services, and Podiatry Services are not covered. Opioid Treatment Program Services have a copay of $10.
Preventive Services See details
The "SCAN Affirm partnered with Included LGBTQ+ Health (HMO)" plan covers preventive services including annual physical exams, health education, personal emergency response systems, in-home support services, support for caregivers of enrollees, fitness benefits, and remote access technologies. However, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, 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 include routine hearing exams and fitting/evaluation for hearing aids, and are covered. Prescription hearing aids (all types) are covered with a copay between $550 and $850, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are covered, including routine eye exams, eyewear (with a combined maximum benefit of $300 per year), contact lenses (1 pair per year), eyeglasses (lenses and frames, 1 pair per year), eyeglass lenses (1 pair per year), and eyeglass frames (1 frame per year). Upgrades are not covered.
Dental Services See details
Dental services include oral exams and dental x-rays, with up to two visits per year, as well as other diagnostic dental services with a copay between $0 and $5. Other preventive dental services are covered with a copay between $0 and $80, while fluoride treatment and orthodontics are not covered. Restorative services have a copay between $8 and $395, and adjunctive general services have a copay between $0 and $125. Endodontics has a copay between $5 and $395, periodontics has a copay between $0 and $380, removable prosthodontics has a copay between $13 and $395, and fixed prosthodontics has a copay between $25 and $395. Oral and maxillofacial surgery has a copay between $0 and $140. Maxillofacial prosthetics and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan, with a copay between $25.00 and $25.00, and prior authorization and a doctor referral are required. There is no coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered under the SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan, including Durable Medical Equipment (DME) and Prosthetics/Medical Supplies - Non-Medicare benefit with no copay or coinsurance, but Durable Medical Equipment for use outside the home, Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Prior authorization is required.
Diagnostic and Radiological Services See details
The Diagnostic and Radiological Services benefit is partially covered by SCAN Affirm partnered with Included LGBTQ+ Health (HMO). Diagnostic Procedures/Tests, Lab Services, and Diagnostic Radiological Services are not covered, and Outpatient X-Ray Services are not covered. Therapeutic Radiological Services are covered with a copay of at most $50.00.
Home Health Services See details
Home Health Services are covered by SCAN Affirm partnered with Included LGBTQ+ Health (HMO) with no copay and no coinsurance, but require prior authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, SET for PAD Services, or Additional Cardiac Rehabilitation Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. Prior authorization and a doctor referral are required.
Other Services See details
The SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan covers acupuncture with prior authorization, and allows for 36 treatments per year. The plan also covers over-the-counter (OTC) items with a maximum benefit of $125 every three months, and provides a meal benefit, with prior authorization. Some services like Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, Private Duty Nursing Services, and others, are not covered.
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