Scripps Heart First offered by SCAN Health Plan (HMO C-SN By SCAN Health Plan
Scripps Heart First offered by SCAN Health Plan (HMO C-SN H5425 055 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.
Scripps Heart First offered by SCAN Health Plan (HMO C-SN H5425-055 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.
The Scripps Heart First offered by SCAN Health Plan (HMO C-SN H5425-055 is available to residents to
Medicare eligible seniors in California.
All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage.
Scripps Heart First offered by SCAN Health Plan (HMO C-SN 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 Scripps Heart First offered by SCAN Health Plan (HMO C-SN 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. Scripps Heart First offered by SCAN Health Plan (HMO C-SN has a monthly drug premium of $26.00 and a $0 drug deductible. This SCAN Health Plan plan offers a $26.00 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. 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 $26.00. 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.
Extra Help Premium Assistance
The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Scripps Heart First offered by SCAN Health Plan (HMO C-SN medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.50 for 75% low-income subsidy $13.00 for 50% and $19.50 for 25%.
Full Assistance Premium:
$0
75% Assistance Premium:
$6.50
50% Assistance Premium:
$13.00
25% Assistance Premium:
$19.50
H5425-055 Formulary and Drug Coverage
Scripps Heart First offered by SCAN Health Plan (HMO C-SN 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.
The benefit information provided is a summary of what Scripps Heart First offered by SCAN Health Plan (HMO C-SN 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.
$0 per day for days 1 through 20 $120 per day for days 21 through 100
Occupational therapy visit
Rehabilitation services
$40 copay
Physical therapy and speech and language therapy visit
Rehabilitation services
$40 copay
Cleaning
Preventive dental
Not covered
Dental x-ray(s)
Preventive dental
Not covered
Fluoride treatment
Preventive dental
Not covered
Oral exam
Preventive dental
Not covered
Preventive care
$0 copay
Outpatient hospital coverage
$35-300 copay per visit
In-Network Other health plan deductibles?
No
Optional supplemental benefits
Yes
Inpatient hospital - psychiatric
Mental health services
$250 per day for days 1 through 7 $0 per day for days 8 through 90
Outpatient group therapy visit
Mental health services
$20 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$35 copay
Outpatient individual therapy visit
Mental health services
$20 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$35 copay
Chemotherapy
Medicare Part B drugs
20% coinsurance
Other Part B drugs
Medicare Part B drugs
20% coinsurance
Diabetes supplies
Medical equipment/supplies
$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
20% coinsurance per item
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$3,400 In-network
Inpatient hospital coverage
$295 per day for days 1 through 7 $0 per day for days 8 through 90
Fitting/evaluation
Hearing
$0 copay
Hearing aids
Hearing
$450-750 copay
Hearing exam
Hearing
$30 copay
Health plan deductible
$0
Ground ambulance
$240 copay
Foot exams and treatment
Foot care (podiatry services)
$25 copay
Routine foot care
Foot care (podiatry services)
$0 copay
Emergency
Emergency care/Urgent care
$90 copay per visit (always covered)
Urgent care
Emergency care/Urgent care
$30 copay per visit (always covered)
Primary
Doctor visits
$15 copay per visit
Specialist
Doctor visits
$35 copay per visit
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$50 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
$0 copay
Diagnostic services
Comprehensive dental
Not covered
Endodontics
Comprehensive dental
Not covered
Extractions
Comprehensive dental
Not covered
Non-routine services
Comprehensive dental
Not covered
Periodontics
Comprehensive dental
Not covered
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
Not covered
Restorative services
Comprehensive dental
Not covered
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
No
CMS Star Ratings
Is Scripps Heart First offered by SCAN Health Plan (HMO C-SN a good plan? Scripps Heart First offered by SCAN Health Plan (HMO C-SN 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 Scripps Heart First offered by SCAN Health Plan (HMO C-SN 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 H5425-055 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 Scripps Heart First offered by SCAN Health Plan (HMO C-SN requires you to live in that plan’s service area. The service area is listed below:
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.
Site Search:
MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.
Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
Every year, Medicare evaluates plans based on a 5-star rating system.
