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2021
Summary of BenefitsSCAN Connections (HMO SNP)
Los Angeles, Riverside and San Bernardino Counties
January 1, 2021 - December 31, 2021
SCAN Connections (HMO SNP) is an HMO plan with a Medicare
contract and a contract with the California Medi-Cal (Medicaid)
program. Enrollment in SCAN Health Plan depends on contract
renewal. SCAN Connections is a Coordinated Care Plan. SCAN
Connections is available to anyone who has both Medical Assistance
from the State and Medicare.The benefit information provided does
not list every service that we cover or list every limitation or
exclusion. To get a complete list of services we cover, please
request the “Evidence of Coverage” by calling our Member Services
Department at the phone number listed in this document or online at
www.scanhealthplan.com.
R1355 08/20 21C-SMB006 Y0057_SCAN_12083_2020F_M DHCS Approved
08172020
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SUMMARY OF BENEFITS JANUARY 1, 2021 – DECEMBER 31, 2021
PREMIUM AND BENEFITS SCAN CONNECTIONS WHAT YOU SHOULD KNOW
Monthly Health Plan Premium You pay $0
Deductible You pay $0 This plan does not have a deductible.
Maximum Out-of-Pocket Responsibility (this does not include
prescription drugs)
$7,550 annually The most you pay for copays and coinsurance for
Medicare- covered medical services for the year.
Inpatient Hospital Coverage You pay $0 Our plan covers an
unlimited number of days for an inpatient hospital stay. Prior
authorization rules apply.
Outpatient Hospital Services
• Ambulatory Surgical Center
• Outpatient Hospital
You pay $0
You pay $0
Prior authorization rules apply for outpatient hospital
services.
Doctor Visits
• Primary Care
• Specialists
You pay $0
You pay $0
Prior authorization rules apply for specialist visits.
Preventive Care You pay $0 Any additional preventive services
approved by Medicare during the contract year will be covered.
Prior authorization rules apply.
Emergency Care You pay $0 You are covered for worldwide
emergency services.
Urgently Needed Services You pay $0 You are covered for
worldwide urgent care services.
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PREMIUM AND BENEFITS SCAN CONNECTIONS WHAT YOU SHOULD KNOW
Diagnostic Services/Labs/ Imaging
• Lab services
• Diagnostic tests and procedures
• Outpatient X-rays
• Therapeutic radiology
• Diagnostic radiology (e.g., MRI, CT)
You pay $0
You pay $0
You pay $0
You pay $0
You pay $0
Prior authorization rules apply for diagnostic, lab, and imaging
services.
Hearing Services
• Medicare-covered diagnostic hearing and balance exam
• Non-Medicare-covered (routine) hearing exam
• Non-Medicare-covered (routine) hearing aids
You pay $0
You pay $0 for up to 1 visit every 12 months
You are covered for select hearing aids every year as medically
necessary.
Prior authorization rules apply for Medicare-covered diagnostic
hearing and balance exams.
You must go to a SCAN-contracted provider to obtain a routine
hearing exam and hearing aids.
Dental Services
• Medicare-covered dental services
You pay $0
Prior authorization rules apply for Medicare-covered dental
services.
Routine dental services do not require prior authorization.
You must go to a SCAN- contracted dentist to obtain routine
dental services.
• Non-Medicare-covered (routine) oral exam
You pay $0
• Non-Medicare-covered (routine) dental cleaning
You pay $0 for up to 2 visits every 12 months
• Non-Medicare-covered (routine) dental X-rays
You pay $0 for up to 1 series every 6 months
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PREMIUM AND BENEFITS SCAN CONNECTIONS WHAT YOU SHOULD KNOW
Vision Services
• Medicare-covered vision exam to diagnose/treat diseases of the
eye
• Medicare-covered glasses after cataract surgery
• Non-Medicare-covered (routine) vision exam
• Non-Medicare-covered (routine) glasses or contact lenses
• Non-Medicare-covered (routine) vision coverage limit
You pay $0
You pay $0
You pay $0 for 1 visit every 12 months
Included within your vision coverage limit
You are covered up to $500 towards the purchase of frames and
lens options or contact lenses every 24 months.
Prior authorization rules apply for Medicare-covered vision exam
and glasses after cataract surgery.
Routine vision services do not require prior authorization.
You must go to a SCAN-contracted vision provider to obtain
routine vision services.
Mental Health Services
• Inpatient visit You pay $0
Prior authorization rules apply for inpatient mental health
hospitalization.
• Outpatient individual/group therapy visit
You pay $0 Prior authorization rules apply for outpatient mental
health services.
• Outpatient individual/group therapy visit with a
psychiatrist
You pay $0
Skilled Nursing Facility You pay $0 Prior authorization rules
apply for skilled nursing facility services.
No prior hospitalization is required.
Physical Therapy You pay $0 Prior authorization rules apply for
outpatient physical therapy services.
Ambulance You pay $0
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PREMIUM AND BENEFITS SCAN CONNECTIONS WHAT YOU SHOULD KNOW
Transportation (Non-Medicare-covered— routine)
You pay $0 for unlimited one-way trips per year
You pay $0 for up to 24 one-way trips per year to non-medical
facilities (grocery store, health club, or senior center). Specific
criteria apply.
75-mile limit applies to each one-way trip. You may qualify for
additional miles beyond the 75-mile limit if deemed medically
necessary. Rides longer than 75 miles require prior
authorization.
Prior authorization rules apply for routine transportation
services.
You must use a SCAN-contracted provider to obtain routine
transportation services.
Medicare Part B Drugs You pay $0 for chemotherapy/radiation
drugs and other Part B drugs
Prior authorization rules apply to select drugs.
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OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS)
Depending on your income and institutional status, you pay the
following:
SCAN CONNECTIONS
Preferred Retail Pharmacy
Standard Retail Pharmacy
Preferred Mail-Order Pharmacy
Standard Mail-Order Pharmacy
Initial Coverage Stage
Tier 1 (Preferred Generic)One-, two- or three-month supply
You pay $0 You pay $0 or $1.30 or $3.70 copay
You pay $0 You pay $0 or $1.30 or $3.70 copay
Tier 2 (Generic)One-, two- or three-month supply
You pay:For generic drugs (including drugs that are treated like
a generic):– $0 or $1.30 or $3.70 copay
For all other drugs:– $0 or $4.00 or $9.20 copay
Tier 3 (Preferred Brand)One-, two- or three-month supply
Tier 4 (Non-Preferred Drug)One-, two- or three-month supply
Tier 5 (Specialty Tier)One-month supply
Catastrophic Coverage Stage You stay in the Initial Coverage
Stage until your yearly out-of-pocket costs reach $6,550. After
your yearly out-of-pocket costs reach $6,550, you will pay $0.
Some of our network pharmacies have preferred cost-sharing. You
may pay less for certain drugs if you use these pharmacies. Your
copays may change depending on the pharmacy you choose, (e.g.,
Preferred Retail, Standard Retail, Preferred Mail-Order, Standard
Mail-Order, Long Term Care (LTC) or Home Infusion, etc.) and when
you enter another phase of the Part D benefit. For more
information, please call our Member Services Department at the
number provided in this document or access your Evidence of
Coverage online.
If you reside in a long-term care facility, your copays are the
same as at a standard retail pharmacy. You may get drugs from an
out-of-network pharmacy, but may pay more than you pay at an
in-network pharmacy.
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ADDITIONAL BENEFITS
Plans may offer supplemental benefits in addition to Part C
benefits and Part D benefits..
BENEFITS SCAN CONNECTIONS WHAT YOU SHOULD KNOW
Acupuncture Services (routine)
You pay $0 for up to 36 visits per year
You do not need a referral for an initial acupuncture visit. Any
subsequent visits require prior authorization.
Chiropractic Services
• Medicare-covered chiropractic care
• Routine chiropractic care
You pay $0
You pay $0 for up to 30 visits per year
Prior authorization rules apply
You do not need a referral for an initial routine chiropractor
visit. Any subsequent visits require prior authorization.
Home Health Care (Medicare-covered)
You pay $0 Prior authorization rules apply
Medical Equipment/Supplies
• Durable Medical Equipment (e.g., wheelchairs, oxygen)
• Prosthetics (e.g., braces, artificial limbs)
You pay $0
You pay $0
Prior authorization rules apply for covered durable medical
equipment, prosthetic devices, and certain diabetic supplies.
• Diabetic supplies You pay $0 SCAN covers diabetic supplies
such as glucose monitors, test strips, and control solution from a
select manufacturer. Lancets are also covered and are available
from all manufacturers.
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BENEFITS SCAN CONNECTIONS WHAT YOU SHOULD KNOW
Telehealth Services You pay $0 A visit with a board-certified
doctor in the comfort of your own home. This benefit is for
non-life threatening conditions such as, but not limited to, cough,
flu, nausea, sore throat, fever, and allergies.
Visits with doctors can be conducted either by telephone or
secure video capabilities from your computer or smart phone.
Over-the-counter Products You pay $0 You are covered up to $100
per quarter for eligible over-the-counter health products available
through the SCAN OTC mail-order catalog.
You are covered up to 2 shipments per quarter and any remaining
balance is carried over to the next quarter. The benefit does not
carry over to the next calendar year.
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SCAN Connections has a network of doctors, hospitals,
pharmacies, and other providers. If you use the providers that are
not in our network, the plan may not pay for these services.
ABOUT SCAN CONNECTIONS
Who can join? You must:
- have both Medicare Part A and Part B- have full Medi-Cal
(Medicaid) benefits- be 65 years of age or older- live in the plan
service area (Los Angeles, Riverside, or San
Bernardino counties, California)- be a United States citizen or
be lawfully present in the
United States- meet criteria for nursing facility level of care
(NFLOC) as
determined by SCAN staff, requiring an annual home visit (in
order to receive long term/personal care services)
- not be enrolled in any Medi-Cal (Medicaid) waiver program such
as, but not limited to, the In-Home Supportive Services (IHSS)
program.
Phone Number (Members)
Phone Number (Non-Members)
TTY
1-866-722-6725
1-877-870-4867 Calling this number will direct you to a licensed
insurance agent.
711
Hours of Operation October 1 to March 31: 8 a.m. to 8 p.m., 7
days a week
April 1 to September 30:8 a.m. to 8 p.m., Monday through
FridayMessages received on holidays and outside of our business
hours will be returned within one business day.
Website www.scanhealthplan.com
To get more information about the coverage and costs of Original
Medicare, look in your current “Medicare & You” handbook. View
it online at www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users call 1-877-486-2048.
This information is not a complete description of benefits. Call
1-866-722-6725 (TTY: 711) for more information.
You can get prescription drugs shipped to your home through our
network mail-order delivery program. Express Scripts PharmacySM is
our Preferred mail order pharmacy. While you can fill your
prescription medications at any of our network mail order
pharmacies, you may pay less at the Preferred mail order pharmacy.
Typically, you should expect to receive your prescription drugs
within 14 days from the time that Express Scripts mail-order
pharmacy receives the order. If you do not receive your
prescription drug(s) within this time, please contact SCAN Health
Plan’s Member Services. For your mail order prescriptions, you have
the option to sign up for an automatic refill program by contacting
Express Scripts Pharmacy at 1-866-553-4125, 24 hours a day, 7 days
a week. TTY users call 711. You may opt out of automatic deliveries
at any time.
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Additional Information about Your Medi-Cal (Medicaid)
BenefitsSCAN Connections (HMO SNP)
The chart below explains all of your covered services available
to you in Medi-Cal Fee-for-Service and as a SCAN Connections
member. If you have any questions about your health care benefits,
please contact SCAN at 1-866-722-6725 from 8 a.m. to 8 p.m., 7 days
a week from October 1 to March 31. From April 1 to September 30,
hours are 8 a.m. to 8 p.m. Monday through Friday (messages received
on holidays and outside of our business hours will be returned
within one business day). TTY: 711.
Members who qualify for both Medicare and Medi-Cal (Medicaid)
health benefits have access to the SCAN Personal Assistance Line
(PAL) Unit. The SCAN PAL Unit is a dedicated group of employees who
are trained to understand the special needs of members who have
both Medicare and Medi-Cal (Medicaid). They are called your “SCAN
PAL.” Each SCAN Connections member is partnered with a SCAN PAL to
answer any questions about benefits, medications, specialty
referrals, and other Medi-Cal (Medicaid) issues or questions.
STATE OF CALIFORNIA MEDICAID (MEDI-CAL) PROGRAM COVERED BENEFITS
FOR DUAL-ELIGIBLE (MEDICARE AND MEDICAID) BENEFICIARIES
BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
1. Acupuncture Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 for up to 36 visits per year as defined by Medicare
and Medi-Cal (Medicaid) services.
2. Acute Administrative Days $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
3. Blood and Blood Derivatives $0 for Medi-Cal-covered
(Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid).
4. California Children Services (CCS)
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
5. Certified Family Nurse Practitioner
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
6. Certified Pediatric Nurse Practitioner Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
7. Child Health and Disability Prevention (CHDP) Program
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
8. Childhood Lead Poisoning Case Management (Provided by the
Local County Health Departments)
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
9. Chiropractic Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 for Medicare-covered chiropractic services.
You pay $0 for non-Medicare-covered (routine) chiropractic
services per year. Limited to 30 visits per year.
10. Chronic Hemodialysis $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
11. Community Based Adult Services (CBAS)
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medi-Cal (Medicaid) services.
12. Comprehensive Perinatal Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
13. Dental Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 for Medicare-covered dental benefits.
You pay $0 for the following non-Medicare-covered (routine)
dental services:
- Dental exams
- Cleaning (limited up to 2 visits every 12 months)
- Dental X-rays (limited up to 1 series every 6 months)
Please call Member Services or the SCAN PAL Unit for additional
dental benefit information.
14. Drug Medi-Cal Substance Abuse Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for Medicare-covered substance abuse services.
Medi-Cal substance abuse services are not covered.
15. Durable Medical Equipment $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 for Medicare-covered durable medical equipment.
You may also be eligible to receive select non-Medicare-covered
bathroom safety equipment as needed. Criteria applies.
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
16. Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) Services and EPSDT Supplemental Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
17. Enhanced Case Management (ECM), as defined in paragraph
95
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for case management services associated with your
SCAN benefits.
Medi-Cal-covered Enhanced Case Management (ECM) services are not
covered.
18. Erectile Dysfunction Drugs $0 for Medi-Cal-covered
(Medicaid) services.
Not covered
19. Expanded Alpha-Fetoprotein Testing (Administered by the
Genetic Disease Branch of DHCS)
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
20. Eyeglasses, Contact Lenses, Low Vision Aids, Prosthetic Eyes
and Other Eye Appliances
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for one pair of Medicare-covered eyeglasses or
contact lenses after cataract surgery.
You are covered up to $500 towards the purchase of frames and
lens options or contact lenses every 24 months.
You pay $0 for Medi-Cal-covered low vision aids, prosthetic eyes
and other eye appliances as medically necessary.
21. Federally Qualified Health Centers (FQHC) (Medi-Cal covered
services only)
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
22. Hearing Aids $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
23. Home and Community-Based Waiver Services (Does not include
EPSDT Services)
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for non-waiver home and community based services as
defined by Medi-Cal services. See Chapter 4 of the EOC.
Home and community based waiver services are not covered.
24. Home Health Agency Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
25. Home Health Aide Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
26. Hospice Care $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
27. Hospital Outpatient Department Services and Organized
Outpatient Clinic Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
28. Human Immunodeficiency Virus and AIDS drugs
$0 for Medi-Cal-covered (Medicaid) services.
For Medicare Part D prescription drugs covered by the plan:
Initial Coverage Stage: For generic drugs (including drugs that
are treated like a generic), you pay:– $0 or $1.30 or $3.70
copay
For all other drugs, you pay: – $0 or $4.00 or $9.20 copay
Catastrophic Coverage Stage: After your yearly out-of-pocket
costs reach $6,550, you pay $0.
You pay $0 for Medicare-covered Part B drugs subject to Medicare
coverage guidelines.
29. Hysterectomy $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
30. Indian Health Services (Medi-Cal covered services only)
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
31. In-Home Medical Care Waiver Services and Nursing Facility
Waiver Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for non-waiver in-home services. See Chapter 4 of the
EOC.
Medi-Cal In-home medical care waiver services are not
covered.
32. Inpatient Hospital Services $0 for Medi-Cal-covered
(Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
33. Intermediate Care Facility Services for the Developmentally
Disabled
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
34. Intermediate Care Facility Services for the Developmentally
Disabled Habilitative
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
35. Intermediate Care Facility Services for the Developmentally
Disabled Nursing
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
36. Intermediate Care Services $0 for Medi-Cal-covered
(Medicaid) services.
Medicare does not cover intermediate care facilities.
You pay $0 for intermediate care facilities as defined in the
SCAN State contract.
37. Laboratory, Radiological and Radioisotope Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
38. Licensed Midwife Services $0 for Medi-Cal-covered (Medicaid)
services.
Not covered
39. Local Educational Agency (LEA) Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
40. Long Term Care (LTC) $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medi-Cal (Medicaid) services.
41. Medical Supplies $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
You pay $0 for incontinence diapers and pad as defined by
Medi-Cal (Medicaid) serives.
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
42. Medical Transportation Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for emergency and non-emergency medical (NEMT) and
non-medical transportation (NMT) services defined by Medicare and
Medi-Cal (Medicaid) guidelines.
You pay $0 for an escort to assist you during transportation to
and from medical and covered non-medical appointments.
Transportation beyond 75 miles requires prior authorization for
NEMT and NMT services.
43. Multipurpose Senior Services Program (MSSP)
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
44. Nurse Anesthetist Services $0 for Medi-Cal-covered
(Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
45. Nurse Midwife Services $0 for Medi-Cal-covered (Medicaid)
services.
Not covered
46. Optometry Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 for non-Medicare-covered (routine) vision services
(refractions) up to 1 eye exam every 12 months.
You are covered up to $500 towards the purchase of frames and
lens options or contact lenses every 24 months.
47. Organized Outpatient Clinic Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
48. Outpatient Heroin Detoxification Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for Medicare-covered outpatient detoxification
services.
Medi-Cal-covered outpatient heroin detoxification services are
not covered.
49. Outpatient Mental Health $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
50. Pediatric Subacute Care Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
51. Personal Care Services $0 for Medi-Cal-covered (Medicaid)
services
You pay $0 for the following services:
- Personal care services: Assistance with bathing, dressing,
eating, getting in and out of bed, moving about/walking, and
grooming.
- Homemaker services: Assistance with light cleaning, grocery
shopping, laundry and meal preparation.
- Home delivered meals: to meet nutritional needs.
- In-home caregiver relief: caregiver services in your home when
your regular caregiver is not available.
- Incontinence supplies: to include creams and washes.
52. Pharmaceutical Services and Prescribed Drugs
$0 for Medi-Cal-covered (Medicaid) services
For Medicare Part D prescription drugs covered by the plan:
Initial Coverage Stage: For generic drugs (including drugs that
are treated like a generic), you pay:– $0 or $1.30 or $3.70
copay
For all other drugs, you pay: – $0 or $4.00 or $9.20 copay
Catastrophic Coverage Stage: After your yearly out-of-pocket
costs reach $6,550, you pay $0.
You pay $0 for Medicare-covered Part B drugs subject to Medicare
coverage guidelines.
You pay $0 for select prescription and over-the-counter drugs
that are covered by the plan under your Medi-Cal (Medicaid)
benefits with a prescription.
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
53. Physical Therapy, Occupational Therapy, Speech Pathology and
Audiological Services
$0 for Medi-Cal-covered (Medicaid) services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
54. Physician Services $0 for Medi-Cal-covered (Medicaid)
services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
55. Podiatry Services $0 for Medi-Cal-covered (Medicaid)
services
You pay $0 for Medicare-covered podiatry services.
You pay $0 for non-Medicare-covered (routine) podiatry services
up to 6 visits per year.
56. Prosthetic and Orthotic Appliances
$0 for Medi-Cal-covered (Medicaid) services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
57. Psychotherapeutic drugs $0 for Medi-Cal-covered (Medicaid)
services
For Medicare Part D prescription drugs covered by the plan:
Initial Coverage Stage: For generic drugs (including drugs that
are treated like a generic), you pay:
– $0 or $1.30 or $3.70 copay
For all other drugs, you pay: – $0 or $4.00 or $9.20 copay
Catastrophic Coverage Stage: After your yearly out-of-pocket
costs reach $6,550, you pay $0.
You pay $0 for Medicare-covered Part B drugs subject to Medicare
coverage guidelines.
58. Rehabilitation Center Outpatient Services
$0 for Medi-Cal-covered (Medicaid) services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
59. Rehabilitation Center Services
$0 for Medi-Cal-covered (Medicaid) services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
60. Renal Homotransplantation $0 for Medi-Cal-covered (Medicaid)
services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
61. Requirements Applicable to EPSDT Supplemental Services
$0 for Medi-Cal-covered (Medicaid) services
Not covered
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:18
I – 18
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
62. Respiratory Care Services $0 for Medi-Cal-covered (Medicaid)
services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
63. Rural Health Clinic Services $0 for Medi-Cal-covered
(Medicaid) services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
64. Scope of Sign Language Interpreter Services
$0 for Medi-Cal-covered (Medicaid) services
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
65. Services provided in a State or Federal Hospital
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
66. Short-Doyle Mental Health Medi-Cal Program Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
67. Skilled Nursing Facility Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
68. Special Duty Nursing $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medi-Cal (Medicaid) services.
69. Specialized Rehabilitative Services in Skilled Nursing
Facilities and Intermediate Care Facilities
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
70. Specialty Mental health services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
71. State Supported Services $0 for Medi-Cal-covered (Medicaid)
services.
Not covered
72. Subacute Care Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 for up to 5 days for post-acute or respite support in
a skilled nursing facility. You may use this service following a
hospital discharge, ER visit or for respite care services.
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:19
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BENEFIT CATEGORY MEDI-CAL (MEDICAID) SCAN CONNECTIONS
73. Swing Bed Services $0 for Medi-Cal-covered (Medicaid)
services.
You pay $0 as defined by Medi-Cal (Medicaid) services.
74. Targeted Case Management Services Program
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
75. Targeted Case Management Services
$0 for Medi-Cal-covered (Medicaid) services.
Not covered
76. Transitional Inpatient Care Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 as defined by Medicare and Medi-Cal (Medicaid)
services.
77. Tuberculosis (TB) Related Services
$0 for Medi-Cal-covered (Medicaid) services.
You pay $0 for Medicare-covered tuberculosis services.
Medi-Cal Tuberculosis related services are not covered.
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:20
I – 20
-
Pre-Enrollment ChecklistBefore making an enrollment decision, it
is important that you fully understand our benefits and rules. If
you have any questions, you can call and speak to a customer
service representative at 1-877-870-4867 (TTY users call 711) Hours
are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31.
From April 1 to September 30 hours are 8 a.m. to 8 p.m., Monday
through Friday. Messages received on holidays and outside of our
business hours will be returned within one business day.
Understanding the Benefits
oReview the full list of benefits found in the Evidence of
Coverage (EOC), especially for those services for which you
routinely see a doctor. Visit www.scanhealthplan.com or call
1-877-870-4867 to view a copy of the EOC.
oReview the provider directory (or ask your doctor) to make sure
the doctors you see now are in the network. If they are not listed,
it means you will likely have to select a new doctor.
oReview the pharmacy directory to make sure the pharmacy you use
for any prescription medicines is in the network. If the pharmacy
is not listed, you will likely have to select a new pharmacy for
your prescriptions.
Understanding Important Rules
oBenefits, premiums and/or copayments/co-insurance may change on
January 1, 2022.
oExcept in emergency or urgent situations, we do not cover
services by out-of-network providers (doctors who are not listed in
the provider directory).
oThis plan is a dual eligible special needs plan (D-SNP). Your
ability to enroll will be based on verification that you are
entitled to both Medicare and medical assistance from a state plan
under Medicaid.
DSNP
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:21
I – 21
-
SCAN Health Plan complies with applicable federal civil rights
laws and does not discriminate, exclude people, or treat them
differently on the basis of, or because of, race, color, national
origin, age, disability, or sex.
SCAN Health Plan provides free aids and services to people with
disabilities to communicate effectively with us, such as qualified
sign language interpreters, and written information in other
formats (large print, audio, accessible electronic formats, other
formats).
SCAN Health Plan provides free language services to people whose
primary language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact SCAN Member Services.
If you believe that SCAN Health Plan has failed to provide these
services or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a
grievance in person, by phone, mail, or fax, at:
SCAN Member Services Attention: Grievance and Appeals Department
P.O. Box 22616, Long Beach, CA 90801-5616 1-800-559-3500 (TTY: 711)
FAX: 1-562-989-5181
Or by filling out the “File a Grievance” form on our website at:
https://www.scanhealthplan.com/contact-us/file-a-grievance
If you need help filing a grievance, SCAN Member Services is
available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at:
U.S. Department of Health and Human Services 200 Independence
Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019 (TTY: 1-800-537-7697)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
SCAN Health Plan is an HMO plan with a Medicare contract.
Enrollment in SCAN Health Plan depends on contract renewal.
This page is intentionally blank.
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:22
I – 22
-
SCAN Health Plan complies with applicable federal civil rights
laws and does not discriminate, exclude people, or treat them
differently on the basis of, or because of, race, color, national
origin, age, disability, or sex.
SCAN Health Plan provides free aids and services to people with
disabilities to communicate effectively with us, such as qualified
sign language interpreters, and written information in other
formats (large print, audio, accessible electronic formats, other
formats).
SCAN Health Plan provides free language services to people whose
primary language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact SCAN Member Services.
If you believe that SCAN Health Plan has failed to provide these
services or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a
grievance in person, by phone, mail, or fax, at:
SCAN Member Services Attention: Grievance and Appeals Department
P.O. Box 22616, Long Beach, CA 90801-5616 1-800-559-3500 (TTY: 711)
FAX: 1-562-989-5181
Or by filling out the “File a Grievance” form on our website at:
https://www.scanhealthplan.com/contact-us/file-a-grievance
If you need help filing a grievance, SCAN Member Services is
available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at:
U.S. Department of Health and Human Services 200 Independence
Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019 (TTY: 1-800-537-7697)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
SCAN Health Plan is an HMO plan with a Medicare contract.
Enrollment in SCAN Health Plan depends on contract renewal.
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:23
I – 23
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English: ATTENTION: If you speak a language other than English,
language assistance services, free of charge, are available to you.
Call 1-800-559-3500. (TTY: 711). Spanish: ATENCIÓN: si habla
español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-800-559-3500. (TTY: 711).
Chinese Traditional: 注意:如果您使用中文,您可以免費獲得語言援助服務。請致電
1-800-559-3500。(TTY: 711)。
Chinese Simplified: 注意:如果您使用中文,您可以免费获得语言援助服务,请致电
1-800-559-3500。(TTY: 711)。 Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng
Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin
vui lòng gọi số 1-800-559-3500. (TTY: 711). Tagalog: PAUNAWA: Kung
nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
tulong sa wika nang walang bayad. Tumawag sa 1-800-559-3500. (TTY:
711).
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-559-3500 번으로 연락해 주십시오. (TTY: 711).
Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա Ձեզ անվճար
կարող են տրամադրվել լեզվական աջակցության ծառայություններ:
Զանգահարե'ք 1-800-559-3500 հեռախոսահամարով: Հեռատիպի համարն է՝
711:
Persian: ت زبایی بوور ت راگگان گفتگو می کنید، تسهیال فارسیاگر به
زبان :توجه .(TTY: 711) ماس بگیرگد.ت 3500-559-800-1شماره برای شما
فراهم می باشد. با
Russian: ВНИМАНИЕ! Если вы говорите по-русски, вы можете
бесплатно получить услуги перевод;а. Звоните по телефону
1-800-559-3500 (TTY: 711). Japanese:
注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。お問合せ先�1-800-559-3500. (TTY:
711).
Arabic: المساعدة اللغوية تتوافر لك ، فإن خدمات العربيةملحوظة:
إذا كنت تتحدث (.711)الهاتف النصي: .3500-559-800-1 برقم اتصل
بالمجان.
Punjabi: ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱ ਚ
ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-800-559-3500 ਉੱਤੇ ਕਾਲ ਕਰੋ।
(TTY: 711)। Mon-Khmer, Cambodian: សូមយកចិត្តទុកដាក់៖ ប
ើសិនជាអ្នកនិយាយភាសាខ្មែរ បសវាជំនួយខ្ននកភាសា បដាយមិនគិត្ថ្លៃ
អាចមានសំរា ់ ំបរ ើអ្នក។ សូមទូរស័ព្ទបៅបេម 1-800-559-3500 ។ (TTY:
711) ។ Hmong: LUS CEEV: Yog tias koj hais lus Hmoob (Ntawv Suav -
Hmoob), muaj kev pab txhais lus pub dawb rau koj. Hu rau
1-800-559-3500. (TTY: 711). Hindi: ध्यान दें: यदद आप द िंदी बोलत े
ैं तो आपके ललए मुफ्त में भाषा स ायता सेवाएिं उपलब्ध ैं। कॉल करें
1-800-559-3500, (TTY: 711)। Thai: โปรดทราบ: ถ้าคณุพดูภาษาไทย
คณุสามารถใช้บริการชว่ยเหลือทางภาษาได้ฟรี โทร 1-800-559-3500 (TTY:
711) Lao: ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື
ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-559-3500
(TTY: 711).
SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf:24
I – 24
21K-PRK900.pdf2021 Star Ratings