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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 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 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.
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 $2600.00 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 a copay or coinsurance depending on the drug tier and pharmacy. 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 and pay nothing for Part D covered drugs. This plan may also reduce your premium if you qualify for the low-income subsidy (LIS).
Additional Benefits
The SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, including some mental health and substance abuse treatments, have low copays. Preventive services, hearing exams, and vision services are covered with no or low copays, and dental services include oral exams and x-rays. This plan also covers ambulance services, with copays, and transportation to health-related locations. Home health services, skilled nursing facilities, and home infusion services are covered, but may require prior authorization or have coinsurance. Additionally, diagnostic, radiological, and medical equipment services are available, but some services like cardiac rehabilitation are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute care with a $150 copay for days 1-7 and no copay for days 8-90, and psychiatric care with a $900 copay for Medicare-covered stays. Additional days for inpatient acute care are covered with no copay, but non-Medicare-covered stays and upgrades for inpatient acute and psychiatric care 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. Individual and group sessions for outpatient substance abuse have a copay of $10, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor's referral. You will have a $25 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services, with a $175 copay for each service. Transportation to plan-approved health-related locations is also covered for up to 24 one-way trips per year, including rideshare, bus/subway, and medical transport. 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 under the SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $90 copay, while Worldwide Emergency Transportation has a $175 copay. Urgently Needed Services has no copay. There is no coinsurance for any of these services.
Primary Care See details
The "SCAN Affirm partnered with Included LGBTQ+ Health (HMO)" plan covers primary care physician services, chiropractic services (with a $10 copay for routine care), occupational therapy services (with a $15 copay), physician specialist services, mental health specialty services (with a $10 copay for individual and group sessions), psychiatric services (with a $15 copay for individual and group sessions), physical therapy and speech-language pathology services (with a $15 copay), additional telehealth benefits, and opioid treatment program services (with a $25 copay). Podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, including services not usually covered by Medicare plans, with services like Health Education, Personal Emergency Response System, Fitness Benefits, Remote Access Technologies, In-Home Support Services, Support for Caregivers of Enrollees, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, covered with no copay. The plan does not cover In-Home Safety Assessment, 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.
Hearing Services See details
The SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan covers hearing exams with no deductible, routine hearing exams once per year, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $550 and $850, with a limit of two per year, but 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 include coverage for eye exams, including routine eye exams once per year, and eyewear such as contact lenses (1 pair every two years), eyeglasses (lenses and frames, 1 pair every two years), eyeglass lenses (1 pair every two years), and eyeglass frames (1 frame every two years). Eyewear has a combined maximum benefit of $300 every two years, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including oral exams and dental x-rays, both limited to 2 visits per year, and other diagnostic dental services and prophylaxis (cleaning), with no visit limits. Fluoride treatment, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
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 between 0-20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with a coinsurance of 0% to 20% and no copay, though Durable Medical Equipment for use outside the home is not covered. This plan also covers Prosthetics/Medical Supplies with a coinsurance of 0% to 20% and no copay, as well as Diabetic Equipment, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $60, and Therapeutic Radiological Services have a coinsurance of at most 20%.
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. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the SCAN Affirm partnered with Included LGBTQ+ Health (HMO) plan. Prior authorization and a doctor referral are required for the services, but the plan does not cover any of the listed sub-services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, 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; there is no coinsurance.
Other Services See details
Other Services offered by SCAN Affirm partnered with Included LGBTQ+ Health (HMO) include acupuncture with a $10 copay and a meal benefit, but Over-the-Counter (OTC) Items, 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 are not covered.
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