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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 San Diego County. 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 $500.00 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 features an Enhanced Alternative drug benefit with a $250 prescription drug deductible. During the initial coverage phase, you will enjoy no copay for Tier 1 preferred generic drugs filled at preferred pharmacies or through preferred mail order, while standard pharmacies and mail options charge a $9 copay. For Tier 2 standard generics, you will pay a $42 copay at preferred pharmacies and mail services, or a $47 copay at standard pharmacies and mail services. Tier 3 preferred brand drugs require a 35% coinsurance, while Tier 4 non-preferred drugs carry a 30% coinsurance across all pharmacy and mail-order options. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, individuals who qualify for the full Low-Income Subsidy can benefit from a $0 Part D premium.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers robust healthcare coverage with no deductibles and mostly no coinsurance for key medical services. Preventive care, urgent care, and primary care visits are covered with no copay, while emergency room visits require a $90 copay that is waived if you are admitted. Inpatient hospital stays are also highly covered, requiring no copay for days one through three and eight through ninety, with only a $50 daily copay for days four through seven. For specialty care, the plan features routine dental, vision, and hearing exams with no copay, alongside a $350 annual allowance for eyewear and a $65 monthly allowance for over-the-counter items. Members also benefit from up to 46 one-way trips to approved medical locations and a $75 copay for ambulance services. Other essential services, such as dialysis and medical equipment, are covered with no copay and coinsurance up to 20%.
Inpatient Hospital See details
SCAN Balance (HMO C-SNP) partially covers inpatient hospital services with no coinsurance, excluding upgrades, non-Medicare-covered stays, and additional psychiatric days. Acute care has no copay for days 1 to 3 and 8 to 90, and a $50 daily copay for days 4 to 7, while psychiatric care requires a $120 daily copay for days 1 to 5 and no copay for days 6 to 90.
Outpatient Services See details
Outpatient services are covered by SCAN Balance (HMO C-SNP) with no coinsurance and copayments ranging from no copay up to $50. Covered benefits include outpatient hospital care, ambulatory surgical center visits, blood services, and outpatient substance abuse sessions which carry a $20 copay.
Partial Hospitalization See details
Partial hospitalization is covered by SCAN Balance (HMO C-SNP) with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required to access these services.
Ambulance and Transportation Services See details
SCAN Balance (HMO C-SNP) covers ground and air ambulance services with a $75 copay and no coinsurance, subject to prior authorization. Transportation services are partially covered, offering up to 46 one-way trips per year to plan-approved health-related locations, while trips to any health-related location are 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 are covered with no copay and no coinsurance, while worldwide emergency services and emergency transportation require copays of $90 and $75, respectively, with no coinsurance.
Primary Care See details
SCAN Balance (HMO C-SNP) covers primary care, specialist, chiropractic, and therapy services with no coinsurance, though prior authorizations and referrals are generally required. Psychiatric and opioid treatment services require a $20 copay with no coinsurance, while podiatry and mental health specialty sessions are not covered.
Preventive Services See details
SCAN Balance (HMO C-SNP) offers partially covered preventive services, including annual physicals, kidney education, and Medicare-covered preventive care with no copay and no coinsurance. However, the plan does not cover medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, smoking cessation, disease management, telemonitoring, home safety modifications, or counseling.
Hearing Services See details
Hearing services are partially covered by SCAN Balance (HMO C-SNP), featuring routine hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids (all types) are limited to two per year with a copay of $450 to $750 and no coinsurance, though OTC hearing aids and inner, outer, or over the ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by SCAN Balance (HMO C-SNP), featuring no deductibles and a $350 annual combined maximum allowance for eyewear, though eyewear upgrades are not covered. Covered benefits include one routine eye exam and one pair of eyeglasses or contact lenses every year, both of which require prior authorization and a doctor referral.
Dental Services See details
Dental services are partially covered by SCAN Balance (HMO C-SNP), though maxillofacial prosthetics, implant services, and orthodontics are not covered. Covered procedures require no coinsurance, with copays ranging from no copay up to $395 depending on the service.
Home Infusion bundled Services See details
SCAN Balance (HMO C-SNP) covers Home Infusion bundled services, which require prior authorization and step therapy. Covered Medicare Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance to 20%, while chemotherapy, radiation, and other Part B drugs have no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
SCAN Balance (HMO C-SNP) covers dialysis services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Medical equipment is partially covered by SCAN Balance (HMO C-SNP), featuring no copay and coinsurance ranging from no coinsurance to 20% for covered items. While durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes are covered, diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by SCAN Balance (HMO C-SNP), with covered therapeutic radiological services requiring no copay and a 20% coinsurance. Other services, including 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 by SCAN Balance (HMO C-SNP), requiring a doctor referral and prior authorization for services to be approved.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the SCAN Balance (HMO C-SNP) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by SCAN Balance (HMO C-SNP), requiring prior authorization and a doctor referral. There is no copay or coinsurance for days 1 through 20, and a $50 copay with no coinsurance for days 21 through 100, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
SCAN Balance (HMO C-SNP) covers other services including unlimited acupuncture treatments and post-hospitalization meal benefits with prior authorization, as well as a $65 monthly allowance for over-the-counter items. Services for Dual Eligible SNPs with Highly Integrated Services are not covered.
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