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SCAN Balance (HMO C-SNP)

H5425 - 104 - 0
4.5 out of 5 stars (4.5 / 5)

SCAN Balance (HMO C-SNP) is a Medicare Advantage Special Needs Plan by SCAN Health Plan.

This page features plan details for 2025 SCAN Balance (HMO C-SNP) H5425 – 104 – 0 available in Riverside and San Bernardino Counties.

Locations

SCAN Balance (HMO C-SNP) is offered in the following locations.

California
Riverside County, California
San Bernardino County, California

Click to see more locations

Plan Overview

SCAN Balance (HMO C-SNP) offers the following coverage and cost-sharing.

Special Needs Plan Type:Chronic or Disabling Condition
Conditions Covered:CardiovascularDisorders, ChronicHeartFailure, DiabetesMellitus
Insurer:SCAN Health Plan
Health Plan Deductible:$0
MOOP:$399 In-network
Drugs Covered:Yes

Ready to sign up for SCAN Balance (HMO C-SNP) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

SCAN Balance (HMO C-SNP) qualifies for a monthly Medicare Give Back Benefit of $53.00.

Premium Reduction:$53.00

Premium Breakdown

SCAN Balance (HMO C-SNP) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $53.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

SCAN Balance (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

SCAN Balance (HMO C-SNP) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00-125.00 Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – 5.00-395.00 Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00-140.00 Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – 0.00-380.00 Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – 25.00-395.00 Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – 13.00-395.00 Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – 8.00-395.00 Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00-5.00 Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00-80.00 Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • $0 copay (Authorization Required, Referral Required)
  • Diagnostic radiology services (e.g., MRI)
    • $0 copay (Authorization Required, Referral Required)
  • Outpatient x-rays
    • $0 copay (Authorization Required, Referral Required)
  • Lab services
    • $0 copay (Authorization Required, Referral Required)

Doctor visits

  • Primary
    • $0 copay
  • Specialist
    • $0 copay (Authorization Required, Referral Required)

Emergency care/Urgent care

  • Emergency
    • $90 copay per visit (always covered)
  • Urgent care
    • $0 copay

Foot care (podiatry services)

  • Foot exams and treatment
    • $0 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • $200 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • $0 copay (Authorization Required, Referral Required)
  • Hearing aids OTC
    • Not covered
  • Hearing aids
    • $550-850 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • $0 copay (Authorization Required, Referral Required)

Inpatient hospital coverage

    • $0 copay (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $399 In-network

Medical equipment/supplies

  • Diabetes supplies
    • $0 copay (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • $0 copay (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • $0 copay (Authorization Required, Referral Required)
  • Outpatient group therapy visit
    • $10 copay (Authorization Required, Referral Required)
  • Outpatient individual therapy visit with a psychiatrist
    • $0 copay (Authorization Required, Referral Required)
  • Outpatient group therapy visit with a psychiatrist
    • $0 copay (Authorization Required, Referral Required)
  • Outpatient individual therapy visit
    • $10 copay (Authorization Required, Referral Required)

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $0-50 copay per visit (Authorization Required, Referral Required)

Preventive care

    • $0 copay (Authorization Required, Referral Required)

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • $0 copay (Authorization Required, Referral Required)
  • Occupational therapy visit
    • $0 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $30 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • $0 copay (Limits Apply)

Vision

  • Contact lenses
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Eyeglass frames
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Eyeglass lenses
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Other
    • Not covered
  • Routine eye exam
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Upgrades
    • Not covered
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply, Authorization Required, Referral Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Dental PPO

Comprehensive Dental

  • Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
    • Monthly Premium: $55.00
    • Max Coverage: $2000.00
    • Coverage Periodicity: Every year

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services
    • Monthly Premium: $55.00
    • Max Coverage: $2000.00
    • Coverage Periodicity: Every year

Ready to sign up for SCAN Balance (HMO C-SNP) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on SCAN Balance (HMO C-SNP)? See 2025 SCAN Balance (HMO C-SNP) at MedicareAdvantageRX.com.

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Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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