2020 SCAN Prime (HMO) H5425-065 By SCAN Health Plan.

2020 Medicare Advantage Plan Services for
SCAN Prime (HMO)


SCAN Prime (HMO) H5425-065 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by SCAN Health Plan available to residents in California. This plan includes additional Medicare prescription drug (Part-D) coverage. The SCAN Prime (HMO) has a monthly premium of $25.00 and has an in-network Maximum Out-of-Pocket limit of $800 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $800 out of pocket. This can be a extremely nice safety net.

SCAN Prime (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.

SCAN Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for SCAN Prime (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from SCAN Health Plan and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from SCAN Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.





2020 SCAN Health Plan Medicare Advantage Plan Details

Name:
SCAN Prime (HMO)
ID:
H5425-065
Provider:SCAN Health Plan
Year:2020
Type: Local HMO
Monthly Premium C+D: $25.00
Part C Premium:$25.00
MOOP: $800
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced




Part-C Premium

SCAN Health Plan plan charges a $25.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



Part-D Deductible and Premium

SCAN Prime (HMO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This SCAN Health Plan plan offers a $0.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by SCAN Health Plan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The SCAN Prime (HMO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$0.00
50% LIS Premium:$0.00
25% LIS Premium:$0.00


Gap Coverage

In 2020 once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This SCAN Health Plan plan does offer additional coverage through the gap.



SCAN Health Plan Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 SCAN Prime (HMO) H5425-065 Formulary here.

Drug Tier Copay
Preferred
Copay
Nonpreferred
1 $0 $5
2 $5 $12
3 $42 $47
4 $95 $100
5 33% 33%
*Initial Coverage Phase and 30 day supply

See the 2020 SCAN Health Plan Formulary





2019 Plan Services

(*2020 Plan services will be added when available)




Health plan deductible


$0



Emergency care/Urgent care


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



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures $0 copay
Lab services $0 copay
Diagnostic radiology services (e.g., MRI) $50
Outpatient x-rays $0 copay



Hearing


Hearing exam $0 copay
Fitting/evaluation $0 copay
Hearing aids $699-999



Preventive dental


Oral exam $13
Cleaning $15
Fluoride treatment Not covered
Dental x-ray(s) $15



Comprehensive dental


Non-routine services Not covered
Diagnostic services $3-15
Restorative services $25-500
Endodontics $25-525
Periodontics $0-375
Extractions $45-125
Prosthodontics, other oral/maxillofacial surgery, other services $0-650



Vision


Routine eye exam $0 copay
Other Not covered
Contact lenses $30
Eyeglasses (frames and lenses) $30
Eyeglass frames $0 copay
Eyeglass lenses $30
Upgrades Not covered



Mental health services


Inpatient hospital - psychiatric $0 copay
Outpatient group therapy visit with a psychiatrist $0 copay
Outpatient individual therapy visit with a psychiatrist $0 copay
Outpatient group therapy visit $0 copay
Outpatient individual therapy visit $0 copay



Skilled Nursing Facility


$0 per day for days 1 through 20
$50 per day for days 21 through 100



Rehabilitation services


Occupational therapy visit $0 copay
Physical therapy and speech and language therapy visit $0 copay



Ground ambulance


$200



Other health plan deductibles?


In-Network No



Transportation


$0 copay



Foot care (podiatry services)


Foot exams and treatment $0 copay
Routine foot care $0 copay



Medical equipment/supplies


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



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


Covered



Medicare Part B drugs


Chemotherapy 20%
Other Part B drugs 20%



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


$1,200 In-network



Optional supplemental benefits


No



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


In-Network No



Inpatient hospital coverage


$0 copay



Outpatient hospital coverage


$0 copay



Doctor visits


Primary $0 copay
Specialist $0 copay



Preventive care


$0 copay


Ratings for SCAN Prime (HMO) H5425

2019 Overall Rating
Part C Summary Rating
Part D Summary 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


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in SCAN Prime (HMO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for SCAN Prime (HMO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


SCAN Prime (HMO) Drug Plan Customer Service ratings

Total Rating
Call Center, TTY, Foreign Language
Appeals Auto
Appeals Upheld


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Coverage Area for SCAN Prime (HMO)

(Click county to compare all available Advantage plans)

State: California
County:Los Angeles,


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Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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