2021 · 2021 Summary of Benefits SCAN Connections (HMO SNP) Los Angeles, Riverside and San...

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

SCAN_38692_21C-SMB006_Cnx_LARVSB_24p.pdf

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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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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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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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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



6. Certified Pediatric Nurse Practitioner Services


Not covered

7. Child Health and Disability Prevention (CHDP) Program


Not covered

8. Childhood Lead Poisoning Case Management (Provided by the Local County Health Departments)


Not covered


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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.


11. Community Based Adult Services (CBAS)


You pay $0 as defined by Medi-Cal (Medicaid) services.

12. Comprehensive Perinatal 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


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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16. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services and EPSDT Supplemental Services


Not covered

17. Enhanced Case Management (ECM), as defined in paragraph 95


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)


Not covered

20. Eyeglasses, Contact Lenses, Low Vision Aids, Prosthetic Eyes and Other Eye Appliances


You pay $0 for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.


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)



22. Hearing Aids $0 for Medi-Cal-covered (Medicaid) services.



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23. Home and Community-Based Waiver Services (Does not include EPSDT 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



25. Home Health Aide Services $0 for Medi-Cal-covered (Medicaid) services.


26. Hospice Care $0 for Medi-Cal-covered (Medicaid) services.


27. Hospital Outpatient Department Services and Organized Outpatient Clinic Services



28. Human Immunodeficiency Virus and AIDS drugs


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.


30. Indian Health Services (Medi-Cal covered services only)




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31. In-Home Medical Care Waiver Services and Nursing Facility Waiver 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.


33. Intermediate Care Facility Services for the Developmentally Disabled


Not covered

34. Intermediate Care Facility Services for the Developmentally Disabled Habilitative


Not covered

35. Intermediate Care Facility Services for the Developmentally Disabled Nursing


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



38. Licensed Midwife Services $0 for Medi-Cal-covered (Medicaid) services.

Not covered

39. Local Educational Agency (LEA) Services


Not covered

40. Long Term Care (LTC) $0 for Medi-Cal-covered (Medicaid) services.


41. Medical Supplies $0 for Medi-Cal-covered (Medicaid) services.


You pay $0 for incontinence diapers and pad as defined by Medi-Cal (Medicaid) serives.


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42. Medical Transportation 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)


Not covered

44. Nurse Anesthetist Services $0 for Medi-Cal-covered (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.


47. Organized Outpatient Clinic Services



48. Outpatient Heroin Detoxification 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.


50. Pediatric Subacute Care Services


Not covered


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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


Initial Coverage Stage: For generic drugs (including drugs that are treated like a generic), you pay:– $0 or $1.30 or $3.70 copay




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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53. Physical Therapy, Occupational Therapy, Speech Pathology and Audiological Services



54. Physician Services $0 for Medi-Cal-covered (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



57. Psychotherapeutic drugs $0 for Medi-Cal-covered (Medicaid) services


Initial Coverage Stage: For generic drugs (including drugs that are treated like a generic), you pay:

– $0 or $1.30 or $3.70 copay




58. Rehabilitation Center Outpatient Services



59. Rehabilitation Center Services



60. Renal Homotransplantation $0 for Medi-Cal-covered (Medicaid) services


61. Requirements Applicable to EPSDT Supplemental Services


Not covered


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62. Respiratory Care Services $0 for Medi-Cal-covered (Medicaid) services


63. Rural Health Clinic Services $0 for Medi-Cal-covered (Medicaid) services


64. Scope of Sign Language Interpreter Services



65. Services provided in a State or Federal Hospital


Not covered

66. Short-Doyle Mental Health Medi-Cal Program Services


Not covered

67. Skilled Nursing Facility Services



68. Special Duty Nursing $0 for Medi-Cal-covered (Medicaid) services.


69. Specialized Rehabilitative Services in Skilled Nursing Facilities and Intermediate Care Facilities


Not covered

70. Specialty Mental health 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.


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73. Swing Bed Services $0 for Medi-Cal-covered (Medicaid) services.


74. Targeted Case Management Services Program


Not covered

75. Targeted Case Management Services


Not covered

76. Transitional Inpatient Care Services



77. Tuberculosis (TB) Related Services


You pay $0 for Medicare-covered tuberculosis services.

Medi-Cal Tuberculosis related services are not covered.


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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


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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.

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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.


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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).


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