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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 Bexar County. The overall rating for this plan is not yet available for 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 $2000.00 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 an enhanced alternative drug benefit with a $0 deductible. During the initial coverage phase, you'll pay different copays or coinsurance amounts depending on the drug tier and pharmacy used. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have a $42 copay at preferred pharmacies. 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 offers a range of benefits with varying cost-sharing. It covers inpatient hospital stays with a copay, as well as outpatient services like primary care, vision, dental, and hearing. You'll find no copays for home health services, and preventive services are covered. This plan includes coverage for emergency services, ambulance services, and partial hospitalization with copays. Additionally, the plan offers benefits such as medical equipment, diagnostic services, and dialysis services with coinsurance. There is also coverage for other services such as acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $95 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $125 copay for days 1-5, and no copay for days 6-90. Additional days and upgrades for Inpatient Hospital-Acute, as well as all Inpatient Hospital Psychiatric 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 (ASC) services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay of $15-$175, ambulatory surgical center (ASC) services have a $15 copay, and individual and group sessions for outpatient substance abuse have a copay of $15.
Partial Hospitalization See details
Partial Hospitalization is covered by the SCAN Balance (HMO C-SNP) plan, with a $55 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services, both with a $225 copay. Transportation Services to a plan-approved health-related location are covered for up to 54 one-way trips per year.
Emergency Services See details
Emergency Services are covered by the SCAN Balance (HMO C-SNP) plan. Emergency Services and Worldwide Emergency Coverage have a $90 copay, Urgently Needed Services and Worldwide Urgent Coverage have a $25 copay, and Worldwide Emergency Transportation has a $225 copay; all services have no coinsurance.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, physician specialist services with a copay between $0 and $15, mental health specialty services with a $15 copay for individual and group sessions, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with a copay between $0 and $25, and opioid treatment program services with a $15 copay. Podiatry services are not covered.
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, support for caregivers of enrollees, 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, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, or counseling services.
Hearing Services See details
Hearing services are covered, including hearing exams, routine hearing exams (1 per year), and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $550 and $850, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $15 copay, and one routine eye exam per year. Eyewear is covered with a combined maximum of $325 per year, and includes one pair of contact lenses, one pair of eyeglasses (lenses and frames), one pair of eyeglass lenses, and one pair of eyeglass frames per year. Upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $15 copay, Oral Exams (2 visits per year), Dental X-Rays (1 per year), Other Diagnostic Dental Services, Prophylaxis (Cleaning) (2 visits per year), Restorative Services, Adjunctive General Services, Endodontics, Periodontics, and Oral and Maxillofacial Surgery; however, Fluoride Treatment, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, and Orthodontics are not covered. Orthodontic Services have a maximum benefit of $2000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance is between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the SCAN Balance (HMO C-SNP) plan, but require prior authorization and a doctor's referral. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0% to 20% coinsurance and no copay, Prosthetics/Medical Supplies with 0% to 20% coinsurance and no copay, and Diabetic Equipment. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay of $30, and Diagnostic Radiological Services with a maximum copay of $125, and Therapeutic Radiological Services with a copay of $30. Lab Services and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered under 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 not covered in practice. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $150. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The "Other Services" benefit includes acupuncture with a $5 copay, and over-the-counter items with a maximum benefit coverage amount of $85 every three months. The plan also offers a meal benefit, and does not cover 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, or Self-Directed Personal Assistance Services.
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