SCAN DaVita Dialysis Care Complete (HMO-POS C-SNP)
Available to residents of Orange County, CA for 2027. Contract H5943, plan 003, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Orange County
- Plan website
- Browse the SCAN DaVita Dialysis Care Complete (HMO-POS C-SNP) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Consolidated into another plan for 2027. CMS carries this plan forward from 2026. Every CA plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,850.00? |
| In- and out-of-network out-of-pocket maximum | $9,850.00 |
| Drug deductible | $175.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO-POS C-SNP? |
| Special needs plan | Chronic-condition SNP |
| Qualifying condition | ChronicKidneyDisease,PostRenalOrganTransplantation |
| Contract / plan | H5943-003-0 |
| Offered by | VillageHealth |
| Parent organization | SCAN Group |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.villagehealthca.com |
| Member services | (877)916-1234TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H5943 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0 copay |
| Other health care professional | $0 copay |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | 20% coinsurance |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 20% coinsurance |
| Lab services | $0 copay |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance |
| Therapeutic radiology | 20% coinsurance |
| Outpatient x-rays | 20% coinsurance |
| Emergency and urgent care | |
| Emergency room | 20% coinsurance |
| Urgent care | 20% coinsurance |
| Worldwide emergency coverage | Not covered |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient hospital services | 20% coinsurance |
| Outpatient observation | 20% coinsurance |
| Ambulatory surgical center | 20% coinsurance |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | Original Medicare cost-sharing(authorization required) |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $0 copay |
| Physical therapy and speech-language therapy | $0 copay |
| Cardiac rehabilitation | 20% coinsurance |
| Pulmonary rehabilitation | 20% coinsurance |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient mental health, individual session | $0 copay |
| Outpatient mental health, group session | $0 copay |
| Psychiatrist, individual session | $0 copay |
| Psychiatrist, group session | $0 copay |
| Partial hospitalization | $0 copay |
| Intensive outpatient program | $0 copay |
| Outpatient substance use, individual session | 20% coinsurance |
| Outpatient substance use, group session | 20% coinsurance |
| Opioid treatment program | 20% coinsurance |
| Ambulance and transportation | |
| Ground ambulance | 20% coinsurance |
| Air ambulance | 20% coinsurance |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance |
| Medical supplies | 0%–20% coinsurance |
| Diabetes supplies | 0%–20% coinsurance |
| Diabetic therapeutic shoes or inserts | $0 copay |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 20% coinsurance |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | $0 copay(limits apply) |
| Other preventive dental services | $0 copay(limits apply) |
| Comprehensive dental plan limit | $2,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay(authorization required) |
| Endodontics (root canals) | $0 copay(authorization required) |
| Periodontics (gum disease) | $0 copay(authorization required) |
| Dentures and other removable prosthodontics | $0 copay(authorization required) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | $0 copay(authorization required) |
| Oral and maxillofacial surgery | $0 copay(authorization required) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | 20% coinsurance |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(limits apply) |
| Eyewear plan limit | $200 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | 20% coinsurance |
| Routine hearing exam | Not covered |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aids (all types) | Not covered |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Not covered |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay(authorization and referral required) |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(authorization and referral required) |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay(authorization and referral required) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | $0 copay(authorization and referral required) |
| Support for caregivers | $0 copay(authorization and referral required) |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $0.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 25% |
| Tier 5 · Specialty Tier | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | no data | 2 out of 5 stars for Breast Cancer Screening |
| Colorectal Cancer Screening · C02 | 2 out of 5 stars for Colorectal Cancer Screening | 2 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 5 out of 5 stars for Annual Flu Vaccine | 5 out of 5 stars for Annual Flu Vaccine |
| Managing Chronic (Long Term) Conditions | ||
| Special Needs Plan (SNP) Care Management · C07 | 2 out of 5 stars for Special Needs Plan (SNP) Care Management | 2 out of 5 stars for Special Needs Plan (SNP) Care Management |
| Care for Older Adults – Medication Review · C08 | no data | 2 out of 5 stars for Care for Older Adults – Medication Review |
| Diabetes Care – Eye Exam · C11 | 3 out of 5 stars for Diabetes Care – Eye Exam | 3 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 1 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 1 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Transitions of Care · C19 | 4 out of 5 stars for Transitions of Care | 2 out of 5 stars for Transitions of Care |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 1 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 1 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | not enough data | 3 out of 5 stars for Getting Needed Care |
| Customer Service · C23 | not enough data | 3 out of 5 stars for Customer Service |
| Rating of Health Plan · C25 | 3 out of 5 stars for Rating of Health Plan | 3 out of 5 stars for Rating of Health Plan |
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 3 out of 5 stars for Rating of Drug Plan | 3 out of 5 stars for Rating of Drug Plan |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 5 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 5 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H5943 shares it.
Also available in 4 other CA counties
Benefits in plain text
SCAN DaVita Dialysis Care Complete (HMO-POS C-SNP) (H5943-003-0) is a 2027 HMO-POS C-SNP Medicare Advantage plan offered by VillageHealth, available to residents of Orange County, CA.
The monthly premium is $0.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,850.00.
The combined in- and out-of-network out-of-pocket maximum is $9,850.00.
The drug deductible is $175.00. Tier 1 and 2 exempt.
It is a special needs plan (Chronic-condition SNP).
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $0.00; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 25%; tier 5 (Specialty Tier): 25%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.