A non-government entity
VillageHealth
Plan ID: H5943-5-0
SCAN DaVita Dialysis Care (HMO-POS C-SNP)
2027 SCAN DaVita Dialysis Care (HMO-POS C-SNP) H5943 — 005 — 0 is a Medicare Advantage plan with drug coverage.
Learn more about SCAN DaVita Dialysis Care (HMO-POS C-SNP) H5943 - 005 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
$0.00 /mo
Monthly premium
$370.00
Drug deductible
$2950.00 / $2950.00
Out-of-pocket maximum (In-Network / Combined)
Enroll online
Call to enroll
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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
Plan Overview
2027 SCAN DaVita Dialysis Care (HMO-POS C-SNP) H5943 — 005 — 0 is a HMO-POS C-SNP offered in Orange, Riverside, and San Bernardino counties by Scan Health Plan. It has a monthly premium of $0.00.
Important:
2027 SCAN DaVita Dialysis Care (HMO-POS C-SNP) H5943 — 005 — 0 is a Chronic or Disabling Condition Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Monthly plan premium
$0.00
Standard Part B premium (estimated)
$209.50
Note:
CMS has not yet announced the official 2027 standard Medicare Part B premium. The estimated 2027 premium is $209.50, per the 2026 Medicare Trustees Report; we'll update this page when CMS publishes the final amount. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
$2950.00
Out-of-pocket maximum (Out-of-Network)
Not applicable
Out-of-pocket maximum (Combined)
$2950.00
Conditions Covered
ChronicKidneyDisease, PostRenalOrganTransplantation
Plan Organization:
Scan Health Plan
Parent Company:
SCAN Group
Plan Type:
HMO-POS C-SNP
Location:
Orange, Riverside, and San Bernardino counties
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$370
Note:
This plan does not charge an annual deductible for all drugs. The $370.00 annual deductible only applies to drugs in certain tiers.
Sign up for SCAN DaVita Dialysis Care (HMO-POS C-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
Drug Coverage
SCAN DaVita Dialysis Care (HMO-POS C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$370.00
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$0.00 | $0.00 |
Initial Coverage Phase
After you meet any applicable drug deductible ($370.00 for this plan), you pay the plan's cost sharing until your out-of-pocket costs for covered Part D drugs, including certain payments made on your behalf, reach $2,400 in 2027. You then enter catastrophic coverage and pay nothing for covered Part D drugs for the rest of the calendar year.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | $0.00 copay | $7.00 copay | $0.00 copay | $7.00 copay |
2. Generic | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
3. Preferred Brand | $42.00 copay | $47.00 copay | $42.00 copay | $47.00 copay |
4. Non-Preferred Drug | 35% coinsurance | 35% coinsurance | 35% coinsurance | 35% coinsurance |
5. Specialty Tier | 29% coinsurance | 29% coinsurance | 29% coinsurance | 29% coinsurance |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,400, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
SCAN DaVita Dialysis Care (HMO-POS C-SNP) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered.
| Days 1-6: | Days 7-90: | |
|---|---|---|
| Copayment | 300.00 | 0.00 |
More Details:
Copayment for Medicare-covered stay
0.00
Additional Days for Inpatient Hospital-Acute
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered.
| Days 1-6: | Days 7-90: | |
|---|---|---|
| Copayment | 300.00 | 0.00 |
More Details:
Copayment for Medicare-covered stay
0.00
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered.
Cost Sharing:
Observation Services
Observation Services benefits are covered.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services
Not covered.
Outpatient Substance Abuse Services
Not covered.
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
40.00
Maximum copayment
40.00
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
40.00
Maximum copayment
40.00
Outpatient Blood Services
Not covered.
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Not covered.
Partial Hospitalization
Not covered.
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered.
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Not covered.
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
Worldwide Emergency Services
Not covered.
Worldwide Emergency Coverage
Not covered.
Worldwide Urgent Coverage
Not covered.
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Not covered.
Chiropractic Services
Chiropractic Services benefits are covered.
Cost Sharing:
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Not covered.
Physician Specialist Services
Not covered.
Mental Health Specialty Services
Not covered.
Individual Sessions for Mental Health Specialty Services
Not covered.
Group Sessions for Mental Health Specialty Services
Not covered.
Podiatry Services
Not covered.
Psychiatric Services
Not covered.
Individual Sessions for Psychiatric Services
Not covered.
Group Sessions for Psychiatric Services
Not covered.
Physical Therapy and Speech-Language Pathology Services
Not covered.
Additional Telehealth Benefits
Not covered.
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Not covered.
Additional Preventive Services
Not covered.
Health Education
Not covered.
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Not covered.
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Not covered.
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Other Preventive Services
Other Preventive Services benefits are covered.
Glaucoma Screening
Not covered.
Diabetes Self-Management Training
Not covered.
Digital Rectal Exams
Not covered.
EKG following Welcome Visit
Not covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Routine Hearing Exams
Not covered.
Fitting/Evaluation for Hearing Aid
Not covered.
Prescription Hearing Aids
Not covered.
Prescription Hearing Aids (all types)
Not covered.
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Not covered.
Routine Eye Exams
Routine Eye Exams benefits are covered.
More Details:
Number of visits
1
Eyewear
Eyewear benefits are covered.
Cost Sharing:
More Details:
Combined maximum amount
200.00
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Number of pairs
1
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
More Details:
Number of eyeglasses
1
Eyeglass lenses
Eyeglass lenses benefits are covered.
More Details:
Number of pairs of lenses
1
Eyeglass frames
Eyeglass frames benefits are covered.
More Details:
Number of eyeglass frames
1
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Not covered.
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Maximum amount
1500.00
Restorative Services
Restorative Services benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Adjunctive General Services
Adjunctive General Services benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Endodontics
Endodontics benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Periodontics
Periodontics benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Prosthodontics, removable
Prosthodontics, removable benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Maxillofacial Prosthetics
Not covered.
Implant Services
Not covered.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
25
Orthodontics
Not covered.
Home Infusion bundled Services
Not covered.
Dialysis Services
Not covered.
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Prosthetics/Medical Supplies - Non-Medicare benefit
Not covered.
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Not covered.
Diabetic Supplies
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts
Not covered.
Diabetic Equipment
Diabetic Equipment benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
Not covered.
Diagnostic Procedures/Tests
Not covered.
Lab Services
Not covered.
All Radiological Services
Not covered.
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
150.00
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
85.00
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
Home Health Services
Not covered.
Cardiac Rehabilitation Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered.
| Days 1-20: | Days 21-100: | |
|---|---|---|
| Copayment | 0.00 | 200.00 |
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Not covered.
Over-the-Counter (OTC) Items
Not covered.
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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