Transcription
2021Summary of BenefitsSCAN Connections (HMO SNP)Los Angeles, Riverside and San Bernardino CountiesJanuary 1, 2021 - December 31, 2021SCAN Connections (HMO SNP) is an HMO plan with a Medicare contract and a contract with the CaliforniaMedi-Cal (Medicaid) program. Enrollment in SCAN Health Plan depends on contract renewal. SCAN Connectionsis a Coordinated Care Plan. SCAN Connections is available to anyone who has both Medical Assistance fromthe 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 ourMember Services Department at the phone number listed in this document or online at www.scanhealthplan.com.R1355 08/20 21C-SMB006Y0057 SCAN 12083 2020F M DHCS Approved 08172020
I–2
SUMMARY OF BENEFITS JANUARY 1, 2021 – DECEMBER 31, 2021PREMIUM AND BENEFITSSCAN CONNECTIONSMonthly Health Plan PremiumYou pay 0DeductibleYou pay 0This plan does not have adeductible.Maximum Out-of-PocketResponsibility (this does notinclude prescription drugs) 7,550 annuallyThe most you pay for copaysand coinsurance for Medicarecovered medical services for theyear.Inpatient Hospital CoverageYou pay 0Our plan covers an unlimitednumber of days for an inpatienthospital stay. Prior authorizationrules apply.Outpatient Hospital Services Ambulatory Surgical CenterYou pay 0 Outpatient HospitalYou pay 0WHAT YOU SHOULD KNOWPrior authorization rules applyfor outpatient hospital services.Doctor VisitsPrior authorization rules applyfor specialist visits. Primary CareYou pay 0 SpecialistsYou pay 0Preventive CareYou pay 0Any additional preventiveservices approved by Medicareduring the contract year willbe covered. Prior authorizationrules apply.Emergency CareYou pay 0You are covered for worldwideemergency services.Urgently Needed ServicesYou pay 0You are covered for worldwideurgent care services.I–3
PREMIUM AND BENEFITSSCAN CONNECTIONSDiagnostic Services/Labs/Imaging Lab servicesYou pay 0 Diagnostic testsand proceduresYou pay 0 Outpatient X-raysYou pay 0 Therapeutic radiologyYou pay 0 Diagnostic radiology (e.g.,MRI, CT)You pay 0WHAT YOU SHOULD KNOWPrior authorization rules applyfor diagnostic, lab, and imagingservices. Medicare-covereddiagnostic hearing andbalance examYou pay 0Prior authorization rules applyfor Medicare-covered diagnostichearing and balance exams. Non-Medicare-covered(routine) hearing examYou pay 0 for up to 1 visitevery 12 monthsYou must go to a SCANcontracted provider to obtaina routine hearing exam andhearing aids. Non-Medicare-covered(routine) hearing aidsYou are covered for selecthearing aids every year asmedically necessary.Hearing ServicesDental Services Medicare-covered dentalservicesYou pay 0Prior authorization rulesapply for Medicare-covereddental services. Non-Medicare-covered(routine) oral examYou pay 0Routine dental services do notrequire prior authorization. Non-Medicare-covered(routine) dental cleaningYou pay 0 for up to 2 visitsevery 12 monthsYou must go to a SCANcontracted dentist to obtainroutine dental services. Non-Medicare-covered(routine) dental X-raysYou pay 0 for up to 1 seriesevery 6 monthsI–4
PREMIUM AND BENEFITSSCAN CONNECTIONSWHAT YOU SHOULD KNOW Medicare-covered visionexam to diagnose/treatdiseases of the eyeYou pay 0Prior authorization rulesapply for Medicare-coveredvision exam and glasses aftercataract surgery. Medicare-covered glassesafter cataract surgeryYou pay 0Routine vision services do notrequire prior authorization. Non-Medicare-covered(routine) vision examYou pay 0 for 1 visit every12 monthsYou must go to a SCANcontracted vision provider toobtain routine vision services. Non-Medicare-covered(routine) glasses orcontact lensesIncluded within your visioncoverage limit Non-Medicare-covered(routine) vision coveragelimitYou are covered up to 500towards the purchase of framesand lens options or contactlenses every 24 months.Vision ServicesMental Health Services Inpatient visitYou pay 0 Outpatient individual/grouptherapy visitYou pay 0 Outpatient individual/grouptherapy visit with apsychiatristYou pay 0Skilled Nursing FacilityPrior authorization rules applyfor inpatient mental healthhospitalization.Prior authorization rules applyfor outpatient mental healthservices.Prior authorization rulesapply for skilled nursingfacility services.You pay 0No prior hospitalization isrequired.Physical TherapyYou pay 0AmbulanceYou pay 0Prior authorization rules applyfor outpatient physical therapyservices.I–5
PREMIUM AND BENEFITSSCAN CONNECTIONSWHAT YOU SHOULD You pay 0 for unlimitedone-way trips per yearPrior authorizationrules apply for routinetransportation services.You pay 0 for up to 24 oneway trips per year to nonmedical facilities (grocery store,health club, or senior center).Specific criteria apply.You must use a SCANcontracted provider to obtainroutine transportation services.75-mile limit applies to eachone-way trip. You may qualifyfor additional miles beyondthe 75-mile limit if deemedmedically necessary. Rideslonger than 75 miles requireprior authorization.Medicare Part B DrugsYou pay 0 for chemotherapy/radiation drugs and other PartB drugsI–6Prior authorization rules applyto select drugs.
OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS)Depending on your income and institutional status, you pay the following:SCAN rPharmacyYou pay 0You pay 0or 1.30 or 3.70 copayYou pay 0You pay 0or 1.30 or 3.70 copayInitial Coverage StageTier 1 (Preferred Generic)One-, two- or three-monthsupplyTier 2 (Generic)One-, two- or three-monthsupplyTier 3 (Preferred Brand)One-, two- or three-monthsupplyYou pay:For generic drugs (including drugs that are treated like a generic):– 0 or 1.30 or 3.70 copayFor all other drugs:– 0 or 4.00 or 9.20 copayTier 4 (Non-Preferred Drug)One-, two- or three-monthsupplyTier 5 (Specialty Tier)One-month supplyCatastrophic Coverage StageYou stay in the Initial Coverage Stage until your yearly out-of-pocketcosts 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 youuse these pharmacies. Your copays may change depending on the pharmacy you choose, (e.g., PreferredRetail, Standard Retail, Preferred Mail-Order, Standard Mail-Order, Long Term Care (LTC) or HomeInfusion, etc.) and when you enter another phase of the Part D benefit. For more information, please callour Member Services Department at the number provided in this document or access your Evidence ofCoverage 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-networkpharmacy.I–7
ADDITIONAL BENEFITSPlans may offer supplemental benefits in addition to Part C benefits and Part D benefits.BENEFITSSCAN CONNECTIONSWHAT YOU SHOULD KNOWAcupuncture Services(routine)You pay 0 for up to 36visits per yearYou do not need a referral for an initialacupuncture visit. Any subsequent visitsrequire prior authorization. Medicare-coveredchiropractic careYou pay 0Prior authorization rules apply Routine chiropractic careYou pay 0 for up to 30visits per yearYou do not need a referral for an initialroutine chiropractor visit. Any subsequentvisits require prior authorization.You pay 0Prior authorization rules apply Durable MedicalEquipment (e.g.,wheelchairs, oxygen)You pay 0Prior authorization rules apply forcovered durable medical equipment,prosthetic devices, and certain diabeticsupplies. Prosthetics (e.g., braces,artificial limbs)You pay 0 Diabetic suppliesYou pay 0Chiropractic ServicesHome Health Care(Medicare-covered)Medical Equipment/SuppliesSCAN covers diabetic supplies such asglucose monitors, test strips, and controlsolution from a select manufacturer.Lancets are also covered and areavailable from all manufacturers.I–8
BENEFITSSCAN CONNECTIONSWHAT YOU SHOULD KNOWTelehealth ServicesYou pay 0A visit with a board-certified doctorin the comfort of your own home.This benefit is for non-life threateningconditions such as, but not limited to,cough, flu, nausea, sore throat, fever,and allergies.Visits with doctors can be conductedeither by telephone or secure videocapabilities from your computer or smartphone.Over-the-counter ProductsYou are covered up to 100 per quarterfor eligible over-the-counter healthproducts available through the SCANOTC mail-order catalog.You pay 0You are covered up to 2 shipments perquarter and any remaining balance iscarried over to the next quarter. Thebenefit does not carry over to the nextcalendar year.I–9
SCAN Connections has a network of doctors, hospitals, pharmacies, and other providers. If you use theproviders that are not in our network, the plan may not pay for these services.ABOUT SCAN CONNECTIONSWho can join?You must:-have both Medicare Part A and Part Bhave full Medi-Cal (Medicaid) benefitsbe 65 years of age or olderlive in the plan service area (Los Angeles, Riverside, or SanBernardino counties, California)- be a United States citizen or be lawfully present in theUnited States- meet criteria for nursing facility level of care (NFLOC) asdetermined 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 programsuch as, but not limited to, the In-Home Supportive Services(IHSS) program.Phone Number (Members)1-866-722-6725Phone Number (Non-Members)1-877-870-4867Calling this number will direct you to alicensed insurance agent.TTY711Hours of OperationOctober 1 to March 31:8 a.m. to 8 p.m., 7 days a weekApril 1 to September 30:8 a.m. to 8 p.m., Monday through FridayMessages received on holidays and outside of our businesshours will be returned within one business day.Websitewww.scanhealthplan.comTo 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 moreinformation.You can get prescription drugs shipped to your home through our network mail-order delivery program. ExpressScripts PharmacySM is our Preferred mail order pharmacy. While you can fill your prescription medications atany 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 mailorder pharmacy receives the order. If you do not receive your prescription drug(s) within this time, pleasecontact SCAN Health Plan’s Member Services. For your mail order prescriptions, you have the option to sign upfor an automatic refill program by contacting Express Scripts Pharmacy at 1-866-553-4125, 24 hours a day, 7days a week. TTY users call 711. You may opt out of automatic deliveries at any time.I – 10
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 asa SCAN Connections member. If you have any questions about your health care benefits, please contactSCAN at 1-866-722-6725 from 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays andoutside 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 SCANPersonal Assistance Line (PAL) Unit. The SCAN PAL Unit is a dedicated group of employees who aretrained 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 toanswer any questions about benefits, medications, specialty referrals, and other Medi-Cal (Medicaid) issuesor questions.STATE OF CALIFORNIA MEDICAID (MEDI-CAL) PROGRAM COVERED BENEFITSFOR DUAL-ELIGIBLE (MEDICARE AND MEDICAID) BENEFICIARIESBENEFIT CATEGORYMEDI-CAL (MEDICAID)SCAN CONNECTIONS1. Acupuncture Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for up to 36 visitsper year as defined by Medicareand Medi-Cal (Medicaid)services.2. Acute Administrative Days 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.3. Blood and Blood Derivatives 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid).4. California Children Services(CCS) 0 for Medi-Cal-covered(Medicaid) services.Not covered5. Certified Family NursePractitioner 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.6. Certified Pediatric NursePractitioner Services 0 for Medi-Cal-covered(Medicaid) services.Not covered7. Child Health and DisabilityPrevention (CHDP) Program 0 for Medi-Cal-covered(Medicaid) services.Not covered8. Childhood Lead PoisoningCase Management(Provided by theLocal County HealthDepartments) 0 for Medi-Cal-covered(Medicaid) services.Not coveredI – 11
BENEFIT CATEGORY9. Chiropractic ServicesMEDI-CAL (MEDICAID) 0 for Medi-Cal-covered(Medicaid) services.SCAN CONNECTIONSYou pay 0 for Medicare-coveredchiropractic services.You pay 0 for non-Medicarecovered (routine) chiropracticservices per year. Limited to 30visits per year.10. Chronic Hemodialysis 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.11. Community Based AdultServices (CBAS) 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedi-Cal (Medicaid) services.12. Comprehensive PerinatalServices 0 for Medi-Cal-covered(Medicaid) services.Not covered13. Dental Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for Medicare-covereddental benefits.You pay 0 for the followingnon-Medicare-covered (routine)dental services:- Dental exams- Cleaning (limited up to 2 visitsevery 12 months)- Dental X-rays (limited up to 1series every 6 months)Please call Member Servicesor the SCAN PAL Unit foradditional dental benefitinformation.14. Drug Medi-Cal SubstanceAbuse Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for Medicare-coveredsubstance abuse services.Medi-Cal substance abuseservices are not covered.15. Durable Medical Equipment 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for Medicare-covereddurable medical equipment.You may also be eligible toreceive select non-Medicarecovered bathroom safetyequipment as needed. Criteriaapplies.I – 12
BENEFIT CATEGORYMEDI-CAL (MEDICAID)SCAN CONNECTIONS16. Early and PeriodicScreening, Diagnosis,and Treatment (EPSDT)Services and EPSDTSupplemental Services 0 for Medi-Cal-covered(Medicaid) services.Not covered17. Enhanced CaseManagement (ECM), asdefined in paragraph 95 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for casemanagement services associatedwith your SCAN benefits.Medi-Cal-covered EnhancedCase Management (ECM)services are not covered.18. Erectile Dysfunction Drugs 0 for Medi-Cal-covered(Medicaid) services.Not covered19. Expanded AlphaFetoprotein Testing(Administered by theGenetic Disease Branchof DHCS) 0 for Medi-Cal-covered(Medicaid) services.Not covered20. Eyeglasses, Contact Lenses,Low Vision Aids, ProstheticEyes and Other EyeAppliances 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for one pair ofMedicare-covered eyeglassesor contact lenses after cataractsurgery.You are covered up to 500towards the purchase of framesand lens options or contactlenses every 24 months.You pay 0 for Medi-Cal-coveredlow vision aids, prosthetic eyesand other eye appliances asmedically necessary.21. Federally Qualified HealthCenters (FQHC) (Medi-Calcovered services only) 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.22. Hearing Aids 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.I – 13
BENEFIT CATEGORY23. Home and CommunityBased Waiver Services(Does not include EPSDTServices)MEDI-CAL (MEDICAID) 0 for Medi-Cal-covered(Medicaid) services.SCAN CONNECTIONSYou pay 0 for non-waiver homeand community based servicesas defined by Medi-Cal services.See Chapter 4 of the EOC.Home and community basedwaiver services are not covered.24. Home Health AgencyServices 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.25. Home Health Aide Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.26. Hospice Care 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.27. Hospital OutpatientDepartment Services andOrganized Outpatient ClinicServices 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.28. Human ImmunodeficiencyVirus and AIDS drugs 0 for Medi-Cal-covered(Medicaid) services.For Medicare Part D prescriptiondrugs covered by the plan:Initial Coverage Stage:For generic drugs (including drugsthat are treated like a generic),you pay:– 0 or 1.30 or 3.70 copayFor all other drugs, you pay:– 0 or 4.00 or 9.20 copayCatastrophic Coverage Stage:After your yearly out-of-pocketcosts reach 6,550, you pay 0.You pay 0 for Medicare-coveredPart B drugs subject to Medicarecoverage guidelines.29. Hysterectomy 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.30. Indian Health Services(Medi-Cal covered servicesonly) 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.I – 14
BENEFIT CATEGORYMEDI-CAL (MEDICAID)SCAN CONNECTIONSYou pay 0 for non-waiverin-home services. See Chapter4 of the EOC.31. In-Home Medical CareWaiver Services andNursing Facility WaiverServices 0 for Medi-Cal-covered(Medicaid) services.32. Inpatient Hospital Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.33. Intermediate CareFacility Services for theDevelopmentally Disabled 0 for Medi-Cal-covered(Medicaid) services.Not covered34. Intermediate CareFacility Services for theDevelopmentally DisabledHabilitative 0 for Medi-Cal-covered(Medicaid) services.Not covered35. Intermediate CareFacility Services for theDevelopmentally DisabledNursing 0 for Medi-Cal-covered(Medicaid) services.Not covered36. Intermediate Care Services 0 for Medi-Cal-covered(Medicaid) services.Medicare does not coverintermediate care facilities.Medi-Cal In-home medical carewaiver services are not covered.You pay 0 for intermediate carefacilities as defined in the SCANState contract.37. Laboratory, Radiologicaland Radioisotope Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.38. Licensed Midwife Services 0 for Medi-Cal-covered(Medicaid) services.Not covered39. Local Educational Agency(LEA) Services 0 for Medi-Cal-covered(Medicaid) services.Not covered40. Long Term Care (LTC) 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedi-Cal (Medicaid) services.41. Medical Supplies 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.You pay 0 for incontinencediapers and pad as defined byMedi-Cal (Medicaid) serives.I – 15
BENEFIT CATEGORY42. Medical TransportationServicesMEDI-CAL (MEDICAID) 0 for Medi-Cal-covered(Medicaid) services.SCAN CONNECTIONSYou pay 0 for emergency andnon-emergency medical (NEMT)and non-medical transportation(NMT) services defined byMedicare and Medi-Cal(Medicaid) guidelines.You pay 0 for an escort toassist you during transportationto and from medical and coverednon-medical appointments.Transportation beyond 75 milesrequires prior authorization forNEMT and NMT services.43. Multipurpose SeniorServices Program (MSSP) 0 for Medi-Cal-covered(Medicaid) services.Not covered44. Nurse Anesthetist Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.45. Nurse Midwife Services 0 for Medi-Cal-covered(Medicaid) services.Not covered46. Optometry Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for non-Medicarecovered (routine) vision services(refractions) up to 1 eye examevery 12 months.You are covered up to 500towards the purchase of framesand lens options or contactlenses every 24 months.47. Organized Outpatient ClinicServices 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.48. Outpatient HeroinDetoxification Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for Medicare-coveredoutpatient detoxification services.Medi-Cal-covered outpatientheroin detoxification services arenot covered.49. Outpatient Mental Health 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.50. Pediatric Subacute CareServices 0 for Medi-Cal-covered(Medicaid) services.Not coveredI – 16
BENEFIT CATEGORY51. Personal Care ServicesMEDI-CAL (MEDICAID) 0 for Medi-Cal-covered(Medicaid) servicesSCAN CONNECTIONSYou pay 0 for thefollowing services:- Personal care services:Assistance with bathing,dressing, eating, getting inand out of bed, moving about/walking, and grooming.- Homemaker services:Assistance with light cleaning,grocery shopping, laundryand meal preparation.- Home delivered meals: tomeet nutritional needs.- In-home caregiver relief:caregiver services in yourhome when your regularcaregiver is not available.- Incontinence supplies: toinclude creams and washes.52. Pharmaceutical Servicesand Prescribed Drugs 0 for Medi-Cal-covered(Medicaid) servicesFor Medicare Part D prescriptiondrugs covered by the plan:Initial Coverage Stage:For generic drugs (includingdrugs that are treated like ageneric), you pay:– 0 or 1.30 or 3.70 copayFor all other drugs, you pay:– 0 or 4.00 or 9.20 copayCatastrophic Coverage Stage:After your yearly out-of-pocketcosts reach 6,550, you pay 0.You pay 0 for Medicare-coveredPart B drugs subject to Medicarecoverage guidelines.You pay 0 for selectprescription and over-thecounter drugs that are coveredby the plan under your Medi-Cal(Medicaid) benefits with aprescription.I – 17
BENEFIT CATEGORYMEDI-CAL (MEDICAID)SCAN CONNECTIONS53. Physical Therapy,Occupational Therapy,Speech Pathology andAudiological Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.54. Physician Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.55. Podiatry Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 for Medicare-coveredpodiatry services.You pay 0 for non-Medicarecovered (routine) podiatryservices up to 6 visits per year.56. Prosthetic and OrthoticAppliances 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.57. Psychotherapeutic drugs 0 for Medi-Cal-covered(Medicaid) servicesFor Medicare Part D prescriptiondrugs covered by the plan:Initial Coverage Stage:For generic drugs (includingdrugs that are treated like ageneric), you pay:– 0 or 1.30 or 3.70 copayFor all other drugs, you pay:– 0 or 4.00 or 9.20 copayCatastrophic Coverage Stage:After your yearly out-of-pocketcosts reach 6,550, you pay 0.You pay 0 for Medicare-coveredPart B drugs subject to Medicarecoverage guidelines.58. Rehabilitation CenterOutpatient Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.59. Rehabilitation CenterServices 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.60. Renal Homotransplantation 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.61. Requirements Applicableto EPSDT SupplementalServices 0 for Medi-Cal-covered(Medicaid) servicesNot coveredI – 18
BENEFIT CATEGORYMEDI-CAL (MEDICAID)SCAN CONNECTIONS62. Respiratory Care Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.63. Rural Health Clinic Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.64. Scope of Sign LanguageInterpreter Services 0 for Medi-Cal-covered(Medicaid) servicesYou pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.65. Services provided in a Stateor Federal Hospital 0 for Medi-Cal-covered(Medicaid) services.Not covered66. Short-Doyle Mental HealthMedi-Cal Program Services 0 for Medi-Cal-covered(Medicaid) services.Not covered67. Skilled Nursing FacilityServices 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.68. Special Duty Nursing 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedi-Cal (Medicaid) services.69. Specialized RehabilitativeServices in Skilled NursingFacilities and IntermediateCare Facilities 0 for Medi-Cal-covered(Medicaid) services.Not covered70. Specialty Mental healthservices 0 for Medi-Cal-covered(Medicaid) services.Not covered71. State Supported Services 0 for Medi-Cal-covered(Medicaid) services.Not covered72. Subacute Care Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for up to 5 days forpost-acute or respite support ina skilled nursing facility. Youmay use this service following ahospital discharge, ER visit orfor respite care services.I – 19
BENEFIT CATEGORYMEDI-CAL (MEDICAID)SCAN CONNECTIONS73. Swing Bed Services 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedi-Cal (Medicaid) services.74. Targeted Case ManagementServices Program 0 for Medi-Cal-covered(Medicaid) services.Not covered75. Targeted Case ManagementServices 0 for Medi-Cal-covered(Medicaid) services.Not covered76. Transitional Inpatient CareServices 0 for Medi-Cal-covered(Medicaid) services.You pay 0 as defined byMedicare and Medi-Cal(Medicaid) services.77. Tuberculosis (TB) RelatedServices 0 for Medi-Cal-covered(Medicaid) services.You pay 0 for Medicarecovered tuberculosis services.Medi-Cal Tuberculosis relatedservices are not covered.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. FromApril 1 to September 30 hours are 8 a.m. to 8 p.m., Monday through Friday. Messages received on holidaysand outside of our business hours will be returned within one business day.Understanding the BenefitsoReview the full list of benefits found in the Evidence of Coverage (EOC), especially for those servicesfor which you routinely see a doctor. Visit www.scanhealthplan.com or call 1-877-870-4867 to viewa copy of the EOC.oReview the provider directory (or ask your doctor) to make sure the doctors you see now are in thenetwork. 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 isin the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for yourprescriptions.Understanding Important RulesoBenefits, 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 onverification that you are entitled to both Medicare and medical assistance from a state plan underMedicaid.DSNPI – 21
This page is intentionally blank.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 communicateeffectively with us, such as qualified sign language interpreters, and written information in otherformats (large print, audio, accessible electronic formats, other formats).SCAN Health Plan provides free language services to people whose primary language is notEnglish, 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 inanother way on the basis of race, color, national origin, age, disability, or sex, you can file agrievance in person, by phone, mail, or fax, at:SCAN Member ServicesAttention: Grievance and Appeals DepartmentP.O. Box 22616, Long Beach, CA 90801-56161-800-559-3500 (TTY: 711)FAX: 1-562-989-5181Or by filling out the “File a Grievance” form on our website a-grievanceIf 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 H
Jan 01, 2021 · SCAN 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 c
