Transcription
Napa and Sonoma CountiesSCAN Classic (HMO)SCAN Compass (HMO)2021 Enrollment KitMedicare Advantage Plan
TA B L E O F C O N T E N T SSECTION ISummary ofBenefitsSECTION IIAdditional PlanInformationSECTION IIIPharmacyBenefitSECTION IVEnrolling in SCAN Health PlanThe SCAN StoryKeeping Seniors Healthy and Independent.That’s been the SCAN mission since theorganization was founded in 1977.We began when a group of senior activists inLong Beach, California got together, determinedto improve access to the care and servicesthey needed so they could stay as independentas possible. They brought together experts inmedicine, gerontology, psychology and socialservices and formed the not-for-profit SeniorCare Action Network, now known as SCAN.More than forty years later, seniors are still at theheart of all we do — and they always will be. Youcan count on SCAN to help you stay healthy,vibrant and connected for years to come.
Sales Appointment ConfirmationPlease initial below beside the type of product(s) you want the agent to discuss.The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of amarketing appointment prior to any sales meeting to ensure understanding of what will be discussedbetween the agent and the Medicare beneficiary (or their authorized representative).Medicare Advantage Plans (Part C) and Cost PlansMedicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that providesall Original Medicare Part A and Part B health coverage and sometimes covers Part D prescriptiondrug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’snetwork (except in emergencies).Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit packagedesigned for people with special health care needs. Examples of the specific groups servedinclude people who have both Medicare and Medicaid, people who reside in nursing homes, andpeople who have certain chronic medical conditions.Optional Supplemental Dental Plans — Administered by Delta Dental Insurance CompanyBy signing this form, you agree to a meeting with a sales agent to discuss the types of products youinitialed above.Agreeing to this appointment does not affect your current or future Medicare enrollment status andthere is no obligation to enroll. In addition, completing this confirmation will not automatically enrollyou in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan.Beneficiary or Authorized Representative Signature and Signature Date:SignatureSignature DateIf you are the authorized representative, please sign above and print below:Representative’s Name:Your Relationship to the Beneficiary:Plan Use Only: To be completed by AgentAgent Name:Agent Phone:Beneficiary Name:Beneficiary Phone (Optional):Beneficiary Address:Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)Agent’s Signature:Date AppointmentCompleted:Plan(s) the agent represented during this meeting:If the form was signed by the beneficiary at time of appointment, provide explanation why SalesAppointment Confirmation was not documented prior to meeting:Sales Appointment Confirmation (Scope of Appointment Form) documentation is subject to CMS recordretention requirements.Y0057 SCAN 11591 2019 C 07232020R1535 08/20 SCAN-SCOPEFORM
SCAN Health Plan - H542520 Medicare Star Ratings*The Medicare Program rates all health and prescription drug plans each year, based on a plan's qualityand performance. Medicare Star Ratings help you know how good a job our plan is doing. You can usethese Star Ratings to compare our plan's performance to other plans. The two main types of Star Ratingsare:1. An Overall Star Rating that combines all of our plan's scores.2. Summary Star Rating that focuses on our medical or our prescription drug services.Some of the areas Medicare reviews for these ratings include: How our members rate our plan's services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications.For 20 , SCAN Health Plan received the following Overall Star Rating from Medicare.Image description. 4.5 Stars End of image description.4.5 StarsWe received the following Summary Star Rating for SCAN Health Plan's health/drug plan services:Image description. 4.5 Stars End of image description.Health Plan Services:4.5 StarsImage description. 4.5 Stars End of image description.Drug Plan Services: 5 StarsImage description. 5 stars End of image description.Image description. 4 stars End of image description.Image description. 3 stars End of image description.Image description. 2 stars End of image description.Image description. 1 star End of image description.The number of stars shows how well our plan performs.5 stars - excellent4 stars - above average3 stars - average2 stars - below average1 star - poorLearn more about our plan and how we are different from other plans at www.medicare.gov.You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time at 1-888-315-7226(toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30are Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time.Current members please call 1-800-559-3500 (toll-free) or 711 (TTY).*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one yearto the next.SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends oncontract renewal.Y0057 SCAN 11 201 ) M 10 201 K-PRK900
Summary ofBenefits
2021Summary of BenefitsSCAN Classic (HMO)and SCAN Compass (HMO)Napa and Sonoma CountiesJanuary 1, 2021 - December 31, 2021SCAN Classic (HMO) and SCAN Compass (HMO) are HMO plans with Medicare contracts. Enrollment in SCANHealth Plan depends on contract renewal.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 MemberServices Department at the phone number listed in this document or online at www.scanhealthplan.com.Y0057 SCAN 12086 2020F MR1358 8/20 21C-SMB150
I–2
SUMMARY OF BENEFITS JANUARY 1, 2021 – DECEMBER 31, 2021PREMIUM AND BENEFITSSCAN CLASSICSCAN COMPASSWHAT YOU SHOULD KNOWMonthly Health PlanPremiumYou pay 34 permonthYou pay 25 permonthYou must continue topay your Medicare Part Bpremium.DeductibleYou pay 0You pay 0This plan does not have adeductible.Maximum Out-of-PocketResponsibility (this does notinclude prescription drugs) 3,400 annually 5,000 annuallyThe most you pay forcopays and coinsurance forMedicare-covered medicalservices for the year.Inpatient Hospital CoverageYou pay 220copay per day fordays 1-8You pay 320copay per day fordays 1-5You pay 0 per dayfor days 9-90 andbeyondYou pay 0 per dayfor days 6-90 andbeyondOur plan covers an unlimitednumber of days for aninpatient hospital stay. Priorauthorization rules apply.Outpatient Hospital ServicesPrior authorization rulesapply for outpatient hospitalservices. Ambulatory SurgicalCenterYou pay 15- 225copay per visitYou pay 15- 225copay per visit Outpatient HospitalYou pay 15- 225copay per visitYou pay 15- 225copay per visit Primary CareYou pay 0You pay 0 SpecialistsYou pay 15 copayper visitYou pay 15 copayper visitPrior authorization rulesapply for specialist visits.Preventive CareYou pay 0You pay 0Any additional preventiveservices approved byMedicare during the contractyear will be covered. Priorauthorization rules apply.Emergency CareYou pay 90 copayper visitYou pay 90 copayper visitThe emergency room copaywill be waived if you areimmediately admitted to thehospital.Doctor VisitsYou are covered forworldwide emergencyservices.I–3
PREMIUM AND BENEFITSSCAN CLASSICSCAN COMPASSWHAT YOU SHOULD KNOWUrgently Needed ServicesYou pay 25 copayper visitYou pay 25 copayper visitYou are covered forworldwide urgent careservices.Diagnostic Services/Labs/ImagingPrior authorization rulesapply for diagnostic, lab,and imaging services. Lab servicesYou pay 0You pay 0 Diagnostic tests andproceduresYou pay 0You pay 0 Outpatient X-raysYou pay 0You pay 0 Therapeutic radiologyYou pay 60 copayper visitYou pay 60 copayper visit Diagnostic radiology (e.g.,MRI, CT)You pay 60 copayper visitYou pay 60 copayper visit Medicare-covereddiagnostic hearing andbalance examYou pay 15 copayper visitYou pay 15 copayper visitPrior authorization rulesapply for Medicare-covereddiagnostic hearing andbalance exams. Non-Medicare-covered(routine) hearing examYou pay 0 for upto 1 visit every 12monthsNot covered Non-Medicare-covered(routine) hearing aidsYou pay 450copay per aidfor a TruHearingAdvanced hearingaid or 750copay per aidfor a TruHearingPremium hearingaidNot coveredYou must go to a SCANcontracted provider to obtaina routine hearing exam andhearing aids.Hearing ServicesYou are covered forup to 2 hearing aidsevery 12 monthsI–4
PREMIUM AND BENEFITSSCAN CLASSICSCAN COMPASSWHAT YOU SHOULD KNOW Medicare-covered dentalservicesYou pay 15 copayper visitYou pay 15 copayper visitPrior authorization rulesapply for Medicare-covereddental services. Non-Medicare-covered(routine) oral examNot coveredYou pay 0 for upto 2 visits every 12months Non-Medicare-covered(routine) dental cleaningNot coveredYou pay 0 for upto 2 visits every 12monthsRoutine dental benefits areavailable with an additionalpremium. See the “OptionalSupplemental Benefits”chart at the end of thisdocument. Non-Medicare-covered(routine) dental X-raysNot coveredYou pay 0 for upto 2 series every 12months Medicare-covered visionexam to diagnose/treatdiseases of the eyeYou pay 15 copayper visitYou pay 15 copayper visit Medicare-covered glassesafter cataract surgeryYou pay 15 copayper pairYou pay 15 copayper pair Non-Medicare-covered(routine) vision examYou pay 0 for upto 1 visit every 12monthsYou pay 0 for upto 1 visit every 12monthsRoutine vision servicesdo not require priorauthorization. Non-Medicare-covered(routine) glasses orcontact lensesYou pay 0 per pairevery 24 monthsYou pay 0 per pairevery 24 months Non-Medicare-covered(routine) vision coveragelimitYou are coveredfor up to 130 forframes or contactlenses every 24monthsYou are coveredfor up to 130 forframes or contactlenses every 24monthsYou must go to a SCANcontracted vision providerto obtain routine visionservices.Dental ServicesVision ServicesI–5Prior authorization rulesapply for Medicare-coveredvision exam and glassesafter cataract surgery.
PREMIUM AND BENEFITSSCAN CLASSICSCAN COMPASSWHAT YOU SHOULD KNOW Inpatient visitYou pay 900copay per admissionfor days 1-90You pay 900copay per admissionfor days 1-90Prior authorization rulesapply for inpatient mentalhealth hospitalization. Youare covered for up to 90days per benefit period.* Outpatient individual/group therapy visitYou pay 25 copayper visitYou pay 25 copayper visit Outpatient individual/group therapy visit with apsychiatristYou pay 15 copayper visitYou pay 15 copayper visitNo prior authorization isrequired for outpatientindividual/group therapyvisits.You pay 0 per dayfor days 1-20You pay 0 per dayfor days 1-20You pay 160copay per day fordays 21-100You pay 160copay per day fordays 21-100Mental Health ServicesSkilled Nursing FacilityPrior authorization rulesapply for skilled nursingfacility services. You arecovered for up to 100 daysper benefit period.*No prior hospitalization isrequired.Physical TherapyYou pay 0You pay 0AmbulanceYou pay 200copay per one-waytripYou pay 200copay per one-waytripTransportation(Non-Medicare- covered—routine)You pay 0 for upto 24 one-way tripsper yearNot covered75-mile limitapplies to each oneway tripMedicare Part B DrugsYou pay 20% ofthe total cost forchemotherapy andother Part B drugsPrior authorization rulesapply for outpatient physicaltherapy services.Prior authorizationrules apply for routinetransportation services.You must use a SCANcontracted provider toobtain routine transportationservices.You pay 20% ofthe total cost forchemotherapy andother Part B drugsPrior authorization rulesapply to select drugs.*A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven’treceived any inpatient hospital or SNF care for 60 days in a row.I–6
OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS):You pay the following:SCAN CLASSICRetailMail-OrderPreferredDrug upplyInitial Coverage StageTier 1(PreferredGeneric)You pay 0You pay 0You pay 7You pay 14You pay 0You pay 14Tier 2(Generic)You pay 10You pay 20You pay 17You pay 34You pay 0You pay 34Tier 3(PreferredBrand)You pay 42You pay 106You pay 47You pay 121You pay 106You pay 121Tier 4(Non-PreferredDrug)You pay 95You pay 265You pay 100You pay 280You pay 265You pay 280Tier 5(Specialty Tier)You pay33%NotavailableYou pay33%NotavailableNotavailableNotavailableCoverage Gap StageBegins after the total yearly drug cost (including what our plan has paidand what you have paid) reaches 4,130.You pay 25% of the negotiated price (and a portion of the dispensing fee)for your brand name drugs and 25% of the cost for your generic drugs.Catastrophic Coverage StageAfter your yearly out-of-pocket drug costs reach 6,550, you pay thegreater of:– 5% of the cost, or– 3.70 copay for generic (including drugs that are treated like ageneric) and 9.20 copay for all other drugs.Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs if you usethese pharmacies. Your cost-sharing may vary depending on the pharmacy you choose (e.g., Preferred Retail,Standard Retail, Preferred Mail-Order, Standard Mail-Order, Long Term Care (LTC), Home infusion, etc.) orwhether you receive a one-month or a three-month supply or when you enter another phase of the Part Dbenefit or if you receive “Extra Help.” For more information, please call our Member Services Department atthe number provided in this document or access your Evidence of Coverage online. If you reside in a longterm care facility, your cost-sharing for a 31-day supply is the same as at a standard retail pharmacy for aI–7
30-day supply. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at anin-network pharmacy.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 tosign up for an automatic refill program by contacting Express Scripts Pharmacy at 1-866-553-4125, 24hours a day, 7 days a week. TTY users call 711. You may opt out of automatic deliveries at any time. Otherpharmacies are available in our network.I–8
OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS):You pay the following:SCAN COMPASSRetailMail-OrderPreferredDrug upplyInitial Coverage StageTier 1(PreferredGeneric)You pay 5You pay 10You pay 10You pay 20You pay 0You pay 20Tier 2(Generic)You pay 15You pay 30You pay 20You pay 40You pay 0You pay 40Tier 3(PreferredBrand)You pay 42You pay 106You pay 47You pay 121You pay 106You pay 121Tier 4(Non-PreferredDrug)You pay 95You pay 265You pay 100You pay 280You pay 265You pay 280Tier 5(Specialty Tier)You pay33%NotavailableYou pay33%NotavailableNotavailableNotavailableCoverage Gap StageBegins after the total yearly drug cost (including what our plan has paidand what you have paid) reaches 4,130.You pay 25% of the negotiated price (and a portion of the dispensing fee)for your brand name drugs and 25% of the cost for your generic drugs.Catastrophic Coverage StageAfter your yearly out-of-pocket drug costs reach 6,550, you pay thegreater of:– 5% of the cost, or– 3.70 copay for generic (including drugs that are treated like ageneric) and 9.20 copay for all other drugs.Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs if you usethese pharmacies. Your cost-sharing may vary depending on the pharmacy you choose (e.g., Preferred Retail,Standard Retail, Preferred Mail-Order, Standard Mail-Order, Long Term Care (LTC), Home infusion, etc.) orwhether you receive a one-month or a three-month supply or when you enter another phase of the Part Dbenefit or if you receive “Extra Help.” For more information, please call our Member Services Department atthe number provided in this document or access your Evidence of Coverage online. If you reside in a longterm care facility, your cost-sharing for a 31-day supply is the same as at a standard retail pharmacy for aI–9
30-day supply. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at anin-network pharmacy.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 tosign up for an automatic refill program by contacting Express Scripts Pharmacy at 1-866-553-4125, 24hours a day, 7 days a week. TTY users call 711. You may opt out of automatic deliveries at any time. Otherpharmacies are available in our network.I – 10
ADDITIONAL BENEFITSPlans may offer supplemental benefits in addition to Part C benefits and Part D benefits.BENEFITSSCAN CLASSICSCAN COMPASSWHAT YOU SHOULD KNOWAcupuncture ServicesYou pay 10 copayfor up to 30 visitsper year combinedwith routinechiropractic servicesYou pay 0 for upto 20 visits peryear combined withroutine chiropracticservicesYou do not need a referralfor an initial acupuncturevisit. Any subsequent visitsrequire prior authorization. Medicare-coveredchiropractic careYou pay 15 copayper visitYou pay 15 copayper visitPrior authorization rulesapply Routine chiropractic careYou pay 10 copayfor up to 30 visitsper year combinedwith acupunctureservicesYou pay 0 for upto 20 visits peryear combined withacupunctureYou do not need a referral foran initial routine chiropractorvisit. Any subsequent visitsrequire prior authorization.You pay 0You pay 0Prior authorization rulesapplyChiropractic ServicesHome Health Care(Medicare-covered)Medical Equipment/Supplies Durable MedicalEquipment (e.g.,wheelchairs, oxygen)You pay 20% of thetotal costYou pay 20% of thetotal cost Prosthetics (e.g., braces,artificial limbs)You pay 20% of thetotal costYou pay 20% of thetotal cost Diabetic suppliesYou pay 0You pay 0I – 11Prior authorization rulesapply for covered durablemedical equipment,prosthetic devices, andcertain diabetic supplies.SCAN covers diabeticsupplies such as glucosemonitors, test strips, andcontrol solution froma select manufacturer.Lancets are also coveredand are available from allmanufacturers.
ADDITIONAL BENEFITSBENEFITSSCAN CLASSICSCAN COMPASSWHAT YOU SHOULD KNOWTelehealth ServicesYou pay 0You pay 0A visit with a board-certifieddoctor in the comfort ofyour own home. This benefitis for non-life threateningconditions such as, butnot limited to, cough, flu,nausea, sore throat, fever,and allergies.Visits with doctors canbe conducted either bytelephone or secure videocapabilities from yourcomputer or smart phone.I – 12
OPTIONAL SUPPLEMENTAL BENEFITSDENTAL SERVICES – SCAN CLASSICBasic Dental PlanMonthly Premium 6 per monthAccess to a large network of Delta Dental DHMO providersOver 270 dental procedures includedPredictable copaymentsLow monthly premium - higher copayments for certain proceduresOnly available in the SCAN Classic planEnhanced Dental PlanMonthly Premium 16 per monthAccess to a large network of Delta Dental DHMO providersOver 300 dental procedures includedPredictable copaymentsMonthly premium - lower copayments for many proceduresOnly available in the SCAN Classic planDENTAL SERVICES – SCAN COMPASSEssential Dental PlanMonthly Premium 10 per monthAccess to a large network of Delta Dental DHMO providersOver 290 dental procedures includedPredictable copaymentsAdditional comprehensive dental coverageOnly available in the SCAN Compass planI – 13
SCAN Classic and SCAN Compass have a network of doctors, hospitals, pharmacies, and other providers. If youuse the providers that are not in our network, the plan may not pay for these services.ABOUT SCAN CLASSIC AND SCAN COMPASSWho can join?You must:– have both Medicare Part A and Part B– live in the plan service area (Napa and Sonoma counties,California)– be a United States citizen or be lawfully present in theUnited StatesPhone Number (Members)1-800-559-3500Phone Number (Non-Members)1-877-870-4867Calling this number will direct you to a licensed 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 business hourswill be returned within one business day.Websitehttp://www.scanhealthplan.comTo get more information about the coverage and costs of Original Medicare, look in your current “Medicare& You” handbook. View it online at https://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 1-800-559-3500 (TTY: 711) for more information.You can get prescription drugs shipped to your home through our network mail-order delivery program, whichis called Express Scripts Pharmacy.SM Typically, you should expect to receive your prescription drugs within14 days from the time that the mail-order pharmacy receives the order. If you do not receive your prescriptiondrug(s) within this time, please contact SCAN Health Plan’s Member Services at 1-800-559-3500, 8 a.m. to8 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 returnedwithin one business day). TTY: 711.I – 14
Pre-Enrollment ChecklistBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If youhave any questions, you can call and speak to a customer service representative at 1-877-870-4867 (TTYusers call 711) Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31. From April 1 toSeptember 30 hours are 8 a.m. to 8 p.m., Monday through Friday. Messages received on holidays and outsideof our business hours will be returned within one business day.Understanding the BenefitsReview the full list of benefits found in the Evidence of Coverage (EOC), especially for those services forwhich you routinely see a doctor. Visit www.scanhealthplan.com or call 1-877-870-4867 to view a copy ofthe EOC.Review 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.Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in thenetwork. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.Understanding Important RulesIn addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. Thispremium is normally taken out of your Social Security check each month.Benefits, premiums and/or copayments/co-insurance may change on January 1, 2022.Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctorswho are not listed in the provider directory).MAI – 15
This page is intentionally blank.I – 16
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 withus, 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 asqualified 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 thebasis of race, color, national origin, age, disability, or sex, you can file a grievance in person, by phone, mail, orfax, 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 Health and Human Services, Office forCivil 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 Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019 (TTY: 1-800-537-7697)Complaint forms are available at AN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends oncontract renewal.I – 17
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 asistencialingüística. Llame al 1-800-559-3500. (TTY: 711).Chinese Traditional: 㲐シ烉 㝄ぐἧ䓐ᷕ㔯炻ぐ ẍ 屣䌚 婆妨 㚵 ˤ婳农暣1-800-559-3500ˤ(TTY: 711)ˤChinese Simplified: ྲ᷌ᛘ֯ ѝ᮷ˈᛘਟԕ ݽ 䍩㧧ᗇ䈝䀰ᨤࣙᴽ ˈ䈧㠤 1-800-5593500ˤ(TTY: 711)ˤVietnamese: CHÚ Ý: NӃu quý vӏ nói TiӃng ViӋt, có các dӏch vө hӛ trӧ ngôn ngӳ miӉn phí dànhcho quý vӏ. Xin vui lòng gӑi sӕ 1-800-559-3500. (TTY: 711).Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ngtulong sa wika nang walang bayad. Tumawag sa 1-800-559-3500. (TTY: 711).Korean: 㭒㦮: 䞲ῃ㠊 㣿䞮㔲⓪ ἓ㤆, 㠎㠊 㰖㤦 ゚㓺 ⶊ 㧊㣿䞮㔺 㑮 㧞㔋 .1-800-559-3500 㦒 G㡆 䟊G㭒㕃㔲㡺UGOTTYaG711PUArmenian: ɡɫɠɊɍɩɡɫɒɞɡɫɟɵ Ɏʀɼ ʄʏʔʏʙʋ ɼʛ ʇɸʌɼʗɼʍ, ɸʑɸ ɚɼɽ ɸʍʕʊɸʗ ʆɸʗʏʉ ɼʍʖʗɸʋɸɻʗʕɼʃ ʃɼɽʕɸʆɸʍ ɸʒɸʆʘʏʙʀʌɸʍ ʅɸʓɸʌʏʙʀʌʏʙʍʍɼʗ: ɏɸʍɺɸʇɸʗɼ ʛ 1-800-559-3500 ʇɼʓɸʄʏʔɸʇɸʋɸʗʏʕ əɼʓɸʖʂʑʂ ʇɸʋɸʗʍ ɾɵ 711 Persian ϥΎ̴ϳ έ ΕέϮμΑ ̶ϧΎΑί ΕϼϴϬδΗ ˬΪϴϨ̯ ̶ϣ Ϯ̴Θϔ̳ ̶γέΎϓ ϥΎΑί ϪΑ ή̳ ϪΟϮΗ (TTY: 711) Ϊϳήϴ̴Α αΎϤΗ 1-800-559-3500 ϩέΎϤη ΎΑ ΪηΎΑ ̶ϣ Ϣϫ ήϓ ΎϤη ̵ ήΑRussian: ȼɇɂɆȺɇɂȿ ȿɫɥɢ ɜɵ ɝɨɜɨɪɢɬɟ ɩɨ-ɪɭɫɫɤɢ ɜɵ ɦɨɠɟɬɟ ɛɟɫɩɥɚɬɧɨ ɩɨɥɭɱɢɬɶ ɭɫɥɭɝɢ ɩɟɪɟɜɨɞ ɚ Ɂɜɨɧɢɬɟ ɩɨ ɬɟɥɟɮɨɧɭ -800-559-3500 (TTY: 711).Japanese: ὀព 㡯㸸᪥ᮏㄒ ヰࡉ ሙྜࠊ ᩱࡢゝㄒᨭ ࡈ ࠸ࡓࡔࡅ ࡍࠋ࠾ၥྜࡏඛ 1-800-559-3500. (TTY: 711).Arabic: ϙϟ έϓ ϭΗΗ ΔϳϭϐϠϟ ΓΩϋΎγϣϟ ΕΎϣΩΧ ϥΈϓ ˬΔϳΑέόϟ ΙΩΣΗΗ Εϧϛ Ϋ· ΔυϭΣϠϣ ϲλϧϟ ϑΗΎϬϟ 1-800-559-3500 ϡϗέΑ ϝλΗ ϥΎΟϣϟΎΑ Punjabi: bQ6R bP Ff Nd S FaUc UhZPf h N Va]a b\NJ D a7Na f\a Nd aKf Z8 WdTN 9SZUQ g 1-800-559-3500 Nf ?aZ ?Yh TTY: 711 Mon-Khmer, Cambodian: ơȄ ŶŻéĆǯŅņŏȁéīéȥɉ ȒŞȋơǯřēƴŚ éřǯžŻŴƤȓîŷ Ƅ ȒơƑĐșřȇŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅȔŊƊ ƷĆŹřơșƇŞȥŞșȒ Ƅ ǶƴŚ éɇ ơȄ ŶŏȄ ƄơȽŬŐȒœȒƉî -800-559-3500 ɇ 77 ɇ Hmong: /86 &((9 RJ WLDV NRM KDLV OXV Hmoob (Ntawv Suav - Hmoob) PXDM NHY SDE txhais luspub GDZE UDX NRM Hu rau 1-800-559-3500. (TTY: 711).Hindi: Ú ȡ Ʌ Ǒ ] Ǒ¡Ȳ ȣ Ȫ ȯ ¡ɇ Ȫ ] ȯ ͧ f ǕÝ Ʌ ȡ ȡ ¡ȡ ȡ ȯ ȡfȲ Þ ¡ɇ@ Ȩ Ʌ 1-800-559-3500 (TTY: 711)@ Thai: à µ o µ » ¡¼ µ µÅ » µ µ Ä o · µ nª Á º µ µ µÅ o à -800-559- 77 /DR ĤĆĀþėą Ăĩ ėďĨ ė ăĨ ėĄĢďĩğ ėĉėĐė Ďėď ùėĄąĭĎęùėĄþĨ ďÿĢđĜ Ġ ĒĀĩ ėĄĉėĐė ĤĀÿąĨĭ ĢĐĖĺûĨ ė ģċĨ ĄċĚĉĩ Ēċĥđĩ ăĨ ėĄ Ĥăč 77 I – 18
Additional PlanInformation
Benefits BeyondOriginal MedicareSCAN offers you benefits beyond what Original Medicare alone provides. For some of thesebenefits, we partner with companies that specialize in that type of care. We are pleased to beable to provide you added coverage through these programs.Good health goes beyond the doctor’s office, so check out your“more than Original Medicare” benefits on the following pages.These program offerings may vary based on plan and county.Please turn to the Summary of Benefits for a detailed descriptionof your plan.For more information on these benefitsCall SCAN at 1-877-870-4867 (TTY: 711)October 1 to March 31: 8 a.m. to 8 p.m., seven days a weekApril 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.You can also visit www.scanhealthplan.com/other-providersOr contact the companies directly –
and SCAN Compass (HMO) Napa and Sonoma Counties January 1, 2021 - December 31, 2021 SCAN Classic (HMO) and SCAN Compass (HMO) are HMO plans with Medicare contracts. Enrollment in SCAN Health Plan depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion.
