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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 San Diego County. 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 $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 has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies or via mail order, and a $9 copay at standard pharmacies. Preferred brand drugs have a 50% coinsurance, and non-preferred drugs have a 33% coinsurance.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers comprehensive coverage, including inpatient and outpatient hospital services with varying copays. You'll find coverage for primary care, preventive services, hearing, vision, and dental, with specific copays and limitations on services like hearing aids and eyewear. Emergency services and ambulance transportation are also covered, as well as home health, dialysis, and medical equipment with varying costs. Additional benefits include coverage for services like acupuncture, over-the-counter items, and a meal benefit. The plan offers coverage for a wide range of services, including mental health, substance abuse, and various therapies. There are some limitations on coverage for certain services, so be sure to review the details to understand your specific costs.
Inpatient Hospital See details
The SCAN Balance (HMO C-SNP) plan covers inpatient hospital stays, including services not usually covered by Medicare plans. For Inpatient Hospital-Acute, there is no copay for days 1-3 and 8-90, and a $50 copay for days 4-7; Inpatient Hospital Psychiatric has a $120 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include outpatient hospital services with a copay between $0 and $50, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Individual and group sessions for outpatient substance abuse have a copay of $20, and outpatient blood services have a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered, with a $55 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $75 copay for both ground and air ambulance services. Transportation services to plan-approved health-related locations are covered for up to 32 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered under the SCAN Balance (HMO C-SNP) plan. Emergency Services and Worldwide Emergency Coverage have a $90 copay, while Worldwide Emergency Transportation has a $75 copay, and there is no coinsurance.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Individual and group sessions for psychiatric services have a $20 copay.
Preventive Services See details
The SCAN Balance (HMO C-SNP) plan covers preventive services, including annual physical exams, health education, in-home safety assessments, personal emergency response systems, fitness benefits, remote access technologies, in-home support services, and support for caregivers of enrollees. The plan does not cover 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.
Hearing Services See details
Hearing Services are covered, including hearing exams, routine hearing exams, and fitting/evaluation for hearing aids. Routine hearing exams are limited to one visit per year. Prescription hearing aids are covered with a copay between $450 and $750, and are limited to two per year; however, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services are covered, including routine eye exams, eyewear, and contact lenses. Routine eye exams are covered once per year, and eyewear has a combined maximum benefit of $350 per year, with contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames also covered once per year; upgrades are not covered.
Dental Services See details
Dental services include coverage for oral exams and dental x-rays, each with 2 visits per year; other diagnostic dental services are covered with a copay between $0 and $5, and other preventive dental services are covered with a copay between $0 and $80. 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, prosthodontics, removable has a copay between $13 and $395, prosthodontics, fixed has a copay between $25 and $395, and oral and maxillofacial surgery has a copay between $0 and $140. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay with a coinsurance between 0-20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0-20%.
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 a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the SCAN Balance (HMO C-SNP) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, and no copay, while Prosthetics and Medical Supplies have a coinsurance between 0% and 20% and no copay; Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, and no copay.
Diagnostic and Radiological Services See details
The SCAN Balance (HMO C-SNP) plan covers therapeutic radiological services with a coinsurance of up to 20%, but diagnostic procedures/tests, lab services, diagnostic radiological services, and outpatient X-ray services are not covered. There is no copay for any of the services.
Home Health Services See details
Home Health Services are covered by the SCAN Balance (HMO C-SNP) plan with no copay and no coinsurance, but require authorization and a referral. 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 referral and prior authorization are required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral. There is no copay for days 1-20, and a $50 copay for days 21-100, but additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture requires prior authorization. OTC items have a maximum benefit of $150 every three months, and the unused amount carries over to the next period. The meal benefit also requires prior authorization. Some services are covered, including 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, 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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