SCAN Balance (HMO C-SNP) Costs & Coverage, Orange County, California
SCAN Balance (HMO C-SNP) Costs & Coverage, Orange County, California
Explore the benefits and costs of SCAN Balance (HMO C-SNP), a 2025 Medicare Special Needs Plan designed to meet your unique healthcare needs. This page provides a comprehensive look at the plan’s benefits and costs, helping you make an informed choice.
Delivery of healthcare services and costs by SCAN Health Plan are different than Original Medicare. This private health insurance option, available to qualified individuals in Orange County, CA, may include additional benefits that are not provided by Medicare Part A and Part B.
As of May 31, 2025, plan enrollments topped 17,161 members, with 5,889 in Orange County, California.
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The SCAN Health Plan logo is a registered trademark.[2]
SCAN Balance Overview
| Plan ID H5425-034-0 Overview | |
|---|---|
| Health Plan ID: | H5425-034-0 |
| Medicare Advantage Plan Type: | HMO C-SNP |
| Plan Year: | 2025 |
| Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $199.00 (In-Network) |
| Part B Give Back: | $0.00/mo |
| Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Additional Benefits: | Vision, Hearing |
| Availability: | Orange County, CA |
| Insured By: | SCAN Health Plan |
We're Here to Help You Enroll
Health Plan Cost Sharing & Benefits
SCAN Balance is a Health Maintenance Organization (HMO) plan. As an HMO member, you typically receive healthcare services through the plan’s local network of providers, with referrals generally required to see specialists and other providers. However, SCAN Balance does cover out-of-network care for emergencies and out-of-area dialysis.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | Not Covered |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $90 Copay |
| Urgent care: | Not Covered |
| Ground ambulance: | $100 Copay |
| Inpatient hospital care: | Coming Soon |
| Skilled Nursing Facility: | Unknown |
This section covers Medicare-approved foot care services, including exams and routine foot care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | Not Covered |
| Routine Foot Care: | Not Covered |
Understand the coverage for Medicare-approved chiropractic services and routine chiropractic care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | Not Covered |
| Routine chiropractic: | Not Covered |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | Not Covered |
| Outpatient group therapy: | Not Covered |
| Inpatient psychiatric hospital care: | Coming Soon |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | Not Covered |
| Occupational therapy: | Not Covered |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | Not Covered |
| Prosthetics: | Not Covered |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | Not Covered |
| Lab services: | Not Covered |
| Outpatient x-rays: | Not Covered |
| Diagnostic tests and procedures: | Not Covered |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
This section details the dental services covered under your plan including Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | Not Covered |
| Oral exam | |
| Dental x-rays | |
| Cleaning | |
| Periodontics | |
| Endodontics | |
| Restorative Services |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Covered Limits may apply |
| Hearing exam | Covered Limits may apply |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | Eyeglasses: Yes Contact Lenses: Yes Eyeglass Lenses: Yes Eyeglass Frames: Yes Eyewear Upgrades: Yes |
Maximum eyewear benefit: | $350.00 Every year |
Do you have questions about the costs in this plan? Call 1-833-748-3201 (TTY 711) to speak with a licensed HealthCompare insurance agent (Mon-Fri 5am-6pm, Sat 6am-5pm PST) and learn more about this Special Needs Plan (H5425-034-0) and other plans on this site.
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
The following table outlines the prescription drug plan premium details of this plan.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Low Income Premium Subsidy: | $29.66 |
| Low Income Premium Subsidy CMS Pays: | $0.00 |
| Low Income Subsidy Premium: | $0.00 |
For more information about the Low Income Subsidy, refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. This is the amount you must pay at the pharmacy before SCAN Health Plan begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, SCAN Balance has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 | $5.00 |
| Generic | $0.00 | $9.00 |
| Preferred Brand | $42.00 | $47.00 |
| Non-Preferred Drug | 50.00% | 50.00% |
| Specialty Tier | 33.00% | 33.00% |
| *Deductible does not apply. | ||
CMS 5-Star Rating Marks
Each year, Medicare Advantage HMO C-SNPs are rated by the Centers for Medicare & Medicaid Services (CMS) across nine categories using a 5-star system. These star ratings are designed to help you assess the quality of care and service offered by this SCAN Health Plan plan.
CMS Star Ratings for Plan H5425-034-0 – 2025
| CMS Measure | Star Rating (out of 5) |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Eligibility Criteria for Enrolling in SCAN Balance
To enroll in SCAN Balance , you must meet the following criteria:
- You are eligible for Medicare;
- You reside within the plan’s service area; and
- You have been diagnosed with one or more severe or disabling chronic conditions.
This plan is for individuals with cardiovascular disorders, chronic heart failure, and/or diabetes.
Important Enrollment Periods
After determining your eligibility for SCAN Balance , it’s important to be aware of the Medicare Enrollment Periods, which determine when you can enroll in or change your plan. Depending on your circumstances, one of the following periods will apply:
- Initial Enrollment Period (IEP): Your first opportunity to enroll when you become eligible for Medicare.
- Annual Enrollment Period (AEP): The time each year when you can change your Medicare plan or enroll in a new one.
- Special Enrollment Periods (SEPs): Times outside of AEP when you can make changes due to specific circumstances, such as moving to a new area or losing other insurance coverage.
For more details on enrollment periods, you can learn more here and make sure you’re well-informed about your Medicare choices.
Contact SCAN Health Plan
Call 833-748-3201 (TTY 711) to speak with a licensed HealthCompare insurance agent (Mon-Fri 5am-6pm, Sat 6am-5pm PST) and learn more about this plan and other plans on this site. You may also Enroll Online.
| Contact Type | Details |
|---|---|
| Website: | SCAN Health Plan Plan Page |
| Providers: | SCAN Health Plan Providers Page |
| Formulary: | SCAN Health Plan Formulary Page |
| Pharmacy: | SCAN Health Plan Pharmacy Page |
| New Member Health Plan Help: | (888)315-7226 |
| New Member Health Plan TTY: | (888)722-6889 |
| New Member Part D Help: | (888)315-7226 |
| New Member Part D TTY Users: | (888)722-6889 |
If you qualify for Medicare benefits but have not yet enrolled or verified your status, visit Social Security Administration website or Medicare.gov.
- SCAN Health Plan, http://www.scanhealthplan.com, Last Accessed June 1, 2025
- CMS.gov, "Chronic Condition Special Needs Plans (C-SNPs)", Last Accessed January 20, 2023
- Medicare.gov, "Compare types of Medicare Advantage Plans", Last Accessed 25 May, 2025
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage", Last Accessed 25 May, 2025
- CMS.gov, Landscape Source Files, Last Accessed October 15, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 15, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 15, 2024
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County, Last Accessed June 6, 2025