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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 Harris 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 a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy used. For example, preferred generic drugs have no copay at preferred pharmacies. For standard generic drugs, the copay is $42.00 at preferred pharmacies. Brand-name and non-preferred drugs have coinsurance costs of 50% and 33%, respectively. After your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The SCAN Balance (HMO C-SNP) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay of $200 for the first few days, but no copay for most days. Outpatient services have copays ranging from $15 to $150, while primary care, chiropractic, and therapy services have a $15 copay. Additional benefits include coverage for emergency services, hearing and vision services, and dental services. The plan also includes home health services with no copay, and skilled nursing facility stays with a copay that varies based on the length of the stay. The plan also covers acupuncture, over-the-counter items, and has a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the SCAN Balance (HMO C-SNP) plan. For Inpatient Hospital-Acute, you will pay a $200 copay for days 1-3, and no copay for days 4-90, with no coinsurance. For Inpatient Hospital Psychiatric, you will pay a $200 copay for days 1-5, and no copay for days 6-90, with no coinsurance. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered Stay for Inpatient Hospital-Acute and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, and outpatient substance abuse services, are covered. Outpatient Hospital Services have a copay of $15 to $150, Ambulatory Surgical Center (ASC) Services have a $15 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a $15 copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including all ambulance services and transportation services to plan-approved health-related locations. Ground and Air Ambulance Services have a $225 copay. 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 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 $20 copay, and Worldwide Emergency Transportation has a $225 copay.
Primary Care See details
The SCAN Balance (HMO C-SNP) plan covers primary care, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, and physical therapy and speech-language pathology services with a $15 copay. The plan also covers physician specialist services with a copay between $0 and $15, mental health specialty services, psychiatric services, additional telehealth benefits with a copay between $0 and $20, 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 Medicare-covered services, 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. Medical nutrition therapy, post discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, 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 counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $15 copay, fitting/evaluation for hearing aids, and prescription hearing aids with a copay between $550 and $850. Prescription hearing aids - 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 eye exams with a $15 copay, and coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames; eyewear has a combined maximum benefit of $250 every two years, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are limited to one pair every two years. Upgrades are not covered.
Dental Services See details
The SCAN Balance (HMO C-SNP) plan covers a variety of dental services, including 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 and fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the SCAN Balance (HMO C-SNP) plan, but require prior authorization. The plan covers Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor's referral. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include 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 include coverage for diagnostic procedures and therapeutic radiological services, with a copay of $30 for diagnostic procedures and a copay of $60 for therapeutic radiological services; however, lab services and outpatient X-ray services are not covered. Diagnostic radiological services have a maximum copay of $150, and therapeutic radiological services have a maximum copay of $60.
Home Health Services See details
Home Health Services are covered by the SCAN Balance (HMO C-SNP) plan with no copay and no coinsurance. However, 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 including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are covered. Prior authorization and a doctor referral are required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the SCAN Balance (HMO C-SNP) plan, with a $0 copay for days 1-20, and a $140 copay for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The SCAN Balance (HMO C-SNP) plan covers acupuncture with a $5 copay and a limit of 20 treatments per year, and over-the-counter items with a maximum benefit of $65 every three months. The plan also covers a meal benefit, and some other services are not covered.
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