SCAN Heart First (HMO C-SNP) By SCAN Health Plan

SCAN Heart First (HMO C-SNP) H5425 080 0 is a 2023 Medicare Advantage Special Needs Plan plan by SCAN Health Plan. This plan from SCAN Health Plan works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up 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. All Medicare SNPs also provide Medicare additional Part-D drug coverage. SCAN Heart First (HMO C-SNP) H5425-080 is a Chronic Condition SNP (C-SNP). A Chronic Condition SNP is for beneficiaries with the following severe or disabling chronic conditions: Cardiovascular Disorders, Chronic Heart Failure and Diabetes. If you have Medicare and you develop certain severe or disabling conditions you can join a Medicare SNP designed to serve people with those conditions at any time.

2023 Medicare Special Needs Plan Details

Plan Name:SCAN Heart First (HMO C-SNP)
Plan ID:H5425 080 0
Special Needs Type:Chronic or Disabling Condition
Provider:SCAN Health Plan
Plan Year:2023
Plan Type:Local HMO
Monthly Premium C+D:$0
Chronic Condition:Cardiovascular Disorders, Chronic Heart Failure and Diabetes
Part C Premium:$0
Part D (Drug) Premium:$0
Part D Supplemental Premium$0
Total Part D Premium:$0
Drug Deductible:$0
Tiers with No Deductible:0
Benchmark:not below the regional benchmark
Type of Medicare Health Plan:Enhanced Alternative
Drug Benefit Type:Enhanced
Gap Coverage:Yes
Similar Plan: H5425-086

The SCAN Heart First (HMO C-SNP) H5425-080 is available to residents to Medicare eligible seniors in California. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. SCAN Heart First (HMO C-SNP) 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 need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.

How much does SCAN Heart First (HMO C-SNP) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. SCAN Health Plan charges a $0 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

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. SCAN Heart First (HMO C-SNP) has a monthly drug premium of $0 and a $0 drug deductible. This SCAN Health Plan plan offers a $0 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. 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. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

SCAN Health Plan Gap Coverage

In 2023 once you and your plan provider have spent $4660 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.

H5425-080 Formulary and Drug Coverage

SCAN Heart First (HMO C-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Tier 1 $0 $5
Tier 2 $0 $10
Tier 3 $40 $47
Tier 4 $90 $100
Tier 5 33% 33%
The complete SCAN Heart First (HMO C-SNP) H5425-080 Formulary
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what SCAN Heart First (HMO C-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from SCAN Health Plan helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

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

Contact lenses

Vision$0 copay

Eyeglass frames

Vision$0 copay

Eyeglass lenses

Vision$0 copay

Eyeglasses (frames and lenses)

Vision$0 copay


VisionNot covered

Routine eye exam

Vision$0 copay


VisionNot covered

Transportation$0 copay
Skilled Nursing Facility$0 per day for days 1 through 20
$150 per day for days 21 through 100

Occupational therapy visit

Rehabilitation services$10 copay

Physical therapy and speech and language therapy visit

Rehabilitation services$10 copay


Preventive dental$0 copay

Dental x-ray(s)

Preventive dental$0 copay

Fluoride treatment

Preventive dentalNot covered

Oral exam

Preventive dental$0 copay

Preventive care$0 copay
Outpatient hospital coverage$10-200 copay per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsYes

Inpatient hospital - psychiatric

Mental health services$200 per day for days 1 through 5
$0 per day for days 6 through 90

Outpatient group therapy visit

Mental health services$20 copay

Outpatient group therapy visit with a psychiatrist

Mental health services$20 copay

Outpatient individual therapy visit

Mental health services$20 copay

Outpatient individual therapy visit with a psychiatrist

Mental health services$20 copay


Medicare Part B drugs20% coinsurance

Other Part B drugs

Medicare Part B drugs20% coinsurance

Diabetes supplies

Medical equipment/supplies$0 copay

Durable medical equipment (e.g., wheelchairs, oxygen)

Medical equipment/supplies0-20% coinsurance per item

Prosthetics (e.g., braces, artificial limbs)

Medical equipment/supplies20% coinsurance per item

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$4,500 In-network
Inpatient hospital coverage$200 per day for days 1 through 5
$0 per day for days 6 through 90


Hearing$0 copay

Hearing aids

Hearing$450-750 copay

Hearing exam

Hearing$0 copay

Health plan deductible$0
Ground ambulance$105 copay

Foot exams and treatment

Foot care (podiatry services)$0 copay

Routine foot care

Foot care (podiatry services)$0 copay


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

Urgent care

Emergency care/Urgent care$25 copay per visit (always covered)


Doctor visits$0 copay


Doctor visits$10 copay per visit

Diagnostic radiology services (e.g., MRI)

Diagnostic procedures/lab services/imaging$100 copay

Diagnostic tests and procedures

Diagnostic procedures/lab services/imaging$0 copay

Lab services

Diagnostic procedures/lab services/imaging$0 copay

Outpatient x-rays

Diagnostic procedures/lab services/imaging$10 copay

Diagnostic services

Comprehensive dental$0 copay


Comprehensive dentalNot covered


Comprehensive dentalNot covered

Non-routine services

Comprehensive dentalNot covered


Comprehensive dental$0 copay

Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dentalNot covered

Restorative services

Comprehensive dentalNot covered

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No

CMS Star Ratings

Is SCAN Heart First (HMO C-SNP) a good plan? SCAN Heart First (HMO C-SNP) received 4.5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Special Needs Plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare SCAN Heart First (HMO C-SNP) performance among several different plans.

2022 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
Monitoring Physical Activity

Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy

Member Experience with H5425-080 Health Plan

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

Member Complaints and Changes in Plans Performance

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

Health Plan Customer Service Rating for SCAN Health Plan

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

Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language

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

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for SCAN Heart First (HMO C-SNP) requires you to live in that plan’s service area. The service area is listed below:

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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