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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 Fresno and Madera 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 $999.00 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 amounts depending on the drug tier and whether you use a preferred or standard pharmacy. For example, preferred generic drugs have no copay, while standard generic drugs have a $47 copay. 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 provides comprehensive healthcare coverage, including inpatient hospital stays with varying copays and outpatient services with copays between $0 and $85. It also offers additional benefits such as ambulance services, dental, vision, hearing, and home health services. This plan includes coverage for emergency services, primary care, and preventive services with no copays for many services, as well as coverage for prescription hearing aids, eyewear, and dental care. Additionally, the plan covers services like home infusion, dialysis, and skilled nursing facility stays, with specific cost-sharing arrangements.
Inpatient Hospital See details
The SCAN Balance (HMO C-SNP) plan covers inpatient hospital services, including acute and psychiatric care. For inpatient hospital-acute, there is no copay for days 1 and 3, a $50 copay for days 4-7, and no copay for days 8-90; additional days are covered with no copay. Inpatient hospital psychiatric has a $120 copay for days 1-10, and no copay for days 11-90; additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services, including all 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 $85, and Individual and Group Sessions for Outpatient Substance Abuse have a $20 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the SCAN Balance (HMO C-SNP) plan, but requires prior authorization and a doctor referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including services not usually covered by Medicare, are offered by SCAN Balance (HMO C-SNP). Ground and air ambulance services have a $75 copay, and transportation services to plan-approved health-related locations are covered for 32 one-way trips per year.
Emergency Services See details
Emergency Services are covered by the SCAN Balance (HMO C-SNP) plan, with a $90 copay and no coinsurance. Worldwide Emergency Coverage has a $90 copay, while Worldwide Emergency Transportation has a $75 copay, and all other services have no copay and no coinsurance.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers Primary Care Physician Services, Chiropractic Services (with a $5 copay for routine care), Occupational Therapy Services (with no copay or coinsurance), Physician Specialist Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services (with no copay or coinsurance), Additional Telehealth Benefits, and Opioid Treatment Program Services with 20% coinsurance. Mental Health Specialty Services, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, Group Sessions for Psychiatric Services, and Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Fitness Benefit, Remote Access Technologies, In-Home Support Services, and Support for Caregivers of Enrollees. 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 Benefit, 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 (1 per year), fitting/evaluation for hearing aids, and prescription hearing aids. Prescription hearing aids have a copay between $550 and $850 for up to 2 hearing aids every year, while inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
The SCAN Balance (HMO C-SNP) plan covers vision services, including eye exams, with no copay, and eyewear with a combined maximum benefit of $300 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are also covered, but upgrades are not covered.
Dental Services See details
Dental services include coverage for oral exams (2 visits per year), dental x-rays (1 per year), other diagnostic dental services, and prophylaxis (cleaning) (2 visits per year). Fluoride treatment, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under 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 is covered under the SCAN Balance (HMO C-SNP) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, and Prosthetic Devices have a coinsurance between 0% and 20%; Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the SCAN Balance (HMO C-SNP) plan, but some services are not covered. There is no copay for any of the covered services. Therapeutic Radiological Services are covered with a coinsurance of at most 20%, while Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services are not covered.
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. A doctor's referral and prior authorization are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral. You will have no copay for days 1-20, and a $50 copay per day for days 21-100.
Other Services See details
The SCAN Balance (HMO C-SNP) plan covers acupuncture with a $5 copay, and over-the-counter (OTC) items up to $95 every three months, as well as a meal benefit. 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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