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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 Francisco 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 $2400.00 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 different copays or coinsurance amounts depending on the drug tier and where you fill your prescription. For example, you will have no copay for preferred generic drugs at a preferred pharmacy or through mail order. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for 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 offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and partial hospitalization with a $25 copay. Emergency, ambulance, and transportation services are covered, along with primary care, preventive services, hearing, vision, and dental care. This plan provides coverage for home infusion, dialysis, medical equipment, and diagnostic and radiological services with copays or coinsurance. It also offers home health services with no copay, skilled nursing facility care with a copay after 20 days, and other services like acupuncture and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits include Inpatient Hospital-Acute, which has a $150 copay for days 1-7, and no copay for days 8-90. Inpatient Hospital Psychiatric has a $900 copay. Non-Medicare-covered stay and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $200, observation services, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a $25 copay for both individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered with a $25 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the SCAN Balance (HMO C-SNP) plan. Ground and air ambulance services have a $175 copay, while transportation services to a plan-approved health-related location are covered for up to 36 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and 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 $175 copay, and there is no coinsurance for any of these services.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services, physician specialist services, mental health specialty services, psychiatric services, additional telehealth benefits, and opioid treatment program services require prior authorization and a doctor referral. Occupational therapy has a $15 copay, and physical therapy and speech-language pathology services have a $15 copay.
Preventive Services See details
The SCAN Balance (HMO C-SNP) plan covers preventive services including health education, in-home safety assessments, personal emergency response systems, fitness benefits, remote access technologies, support for caregivers, and in-home support services. 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, home and bathroom safety devices and modifications, or counseling services.
Hearing Services See details
Hearing services are covered, including routine hearing exams and fitting/evaluation for hearing aids. Routine hearing exams are limited to 1 per year, and fitting/evaluation for hearing aids has no limit. Prescription hearing aids (all types) are covered with a copay between $550 and $850, limited to 2 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, along with OTC hearing aids.
Vision Services See details
Vision Services are covered by the SCAN Balance (HMO C-SNP) plan, including routine eye exams with no deductible, and eyewear with a combined maximum of $300 every two years. This plan covers one pair of contact lenses, one pair of eyeglasses (lenses and frames), one pair of eyeglass lenses, and one pair of eyeglass frames every two years, but does not cover upgrades.
Dental Services See details
The SCAN Balance (HMO C-SNP) plan covers a variety of dental services. Oral exams and cleanings are covered up to two times per year, and dental x-rays are covered once per year. Fluoride treatments, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, and orthodontics are not covered, and orthodontic services have a maximum benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. 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 by the SCAN Balance (HMO C-SNP) plan and require prior authorization and a doctor's referral. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay and a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the SCAN Balance (HMO C-SNP) plan, but Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $60.00, while Therapeutic Radiological Services have a coinsurance of at most 20%.
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 both 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 none of the sub-services are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD 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 Balance (HMO C-SNP) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $125 copay for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays, are not covered.
Other Services See details
Other Services include acupuncture and a meal benefit, both of which require prior authorization, while other services are not covered. The plan covers acupuncture with no copay or coinsurance, and a meal benefit for specific circumstances.
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